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CSCCa and NSCA Joint Consensus Guidelines for Transition Periods: Safe Return to Training Following Inactivity

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CSCCa and NSCA Joint Consensus Guidelines for Transition Periods: Safe Return to Training Following Inactivity

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THE INCIDENCE OF INJURIES AND DEATHS RELATED TO EXERTIONAL HEAT ILLNESS (EHI), EXERTIONAL RHABDOMYOLYSIS (ER), AND CARDIORESPIRATORY FAILURE HAS INCREASED SIGNIFICANTLY IN COLLEGE ATHLETES IN RECENT YEARS. DATA INDICATE THAT THESE INJURIES AND DEATHS ARE MORE LIKELY TO OCCUR DURING PERIODS WHEN ATHLETES ARE TRANSITIONING FROM RELATIVE INACTIVITY TO REGULAR TRAIN- ING. TO ADDRESS THIS PROBLEM, THE CSCCA AND NSCA HAVE CREATED CONSENSUS GUIDE- LINES WHICH RECOMMEND UPPER LIMITS ON THE VOLUME, INTENSITY, AND WORK:REST RATIO DURING TRANSITION PERI- ODS WHERE ATHLETES ARE MOST VULNERABLE. THE CONSENSUS GUIDELINES PROVIDE STRENGTH AND CONDITIONING COACHES WITH A CLEAR FRAMEWORK FOR SAFE AND EFFECTIVE PROGRAM DESIGN IN THE FIRST 2-4 WEEKS FOLLOWING PERIODS OF INAC- TIVITY OR RETURN FROM EHI OR ER. ADHERING TO THE CONSEN- SUS GUIDELINES, CONDUCTING PREPARTICIPATION MEDICAL EVALUATIONS, AND ESTABLISH- ING EMERGENCY ACTION PLANS WILL REDUCE THE INCIDENCE OF INJURIES AND DEATHS IN COL- LEGE ATHLETES
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CSCCa and NSCA Joint
Consensus Guidelines for
Transition Periods: Safe
Return to Training
Following Inactivity
Anthony Caterisano, Co-Chair,
1
Donald Decker, Co-Chair,
2
Ben Snyder, Co-Chair,
1
Matt Feigenbaum,
1
Rob Glass,
3
Paul House,
4
Carwyn Sharp,
5
Michael Waller,
6
and Zach Witherspoon
2
1
Furman University, Greenville, South Carolina;
2
New Mexico State University, Las Cruces, New Mexico;
3
Oklahoma
State University, Stillwater, Oklahoma;
4
Oklahoma Christian University, Oklahoma City, Oklahoma;
5
United States
Olympic Committee, Colorado Springs, Colorado; and
6
Arkansas Tech University, Russellville, Arkansas
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided
in the HTML and PDF versions of this article on the journal’s Web site (http://journals.lww.com/nsca-scj).
ABSTRACT
THE INCIDENCE OF INJURIES AND
DEATHS RELATED TO EXERTIONAL
HEAT ILLNESS (EHI), EXERTIONAL
RHABDOMYOLYSIS (ER), AND
CARDIORESPIRATORY FAILURE
HAS INCREASED SIGNIFICANTLY
IN COLLEGE ATHLETES IN RECENT
YEARS. DATA INDICATE THAT
THESE INJURIES AND DEATHS ARE
MORE LIKELY TO OCCUR DURING
PERIODS WHEN ATHLETES ARE
TRANSITIONING FROM RELATIVE
INACTIVITY TO REGULAR TRAIN-
ING. TO ADDRESS THIS PROBLEM,
THE CSCCA AND NSCA HAVE
CREATED CONSENSUS GUIDE-
LINES WHICH RECOMMEND
UPPER LIMITS ON THE VOLUME,
INTENSITY, AND WORK:REST
RATIO DURING TRANSITION PERI-
ODS WHERE ATHLETES ARE MOST
VULNERABLE. THE CONSENSUS
GUIDELINES PROVIDE STRENGTH
AND CONDITIONING COACHES
WITH A CLEAR FRAMEWORK FOR
SAFE AND EFFECTIVE PROGRAM
DESIGN IN THE FIRST 2–4 WEEKS
FOLLOWING PERIODS OF INAC-
TIVITY OR RETURN FROM EHI OR
ER. ADHERING TO THE CONSEN-
SUS GUIDELINES, CONDUCTING
PREPARTICIPATION MEDICAL
EVALUATIONS, AND ESTABLISH-
ING EMERGENCY ACTION PLANS
WILL REDUCE THE INCIDENCE OF
INJURIES AND DEATHS IN COL-
LEGE ATHLETES.
INTRODUCTION
OVERVIEW
Since 1982, the National Collegiate
Athletic Association (NCAA) and
the National Athletic Trainers’
Association (NATA) have collaborated
to maintain the largest ongoing colle-
giate sports injury database in the world
(36). Data from the NCAA Injury Sur-
veillance Program (https://www.ncaa.
org/sport-science-institute/ncaa-injury-
surveillance-program) indicate that,
among all 25 NCAA sports programs,
football consistently has the highest
injury rates for both games (35.9 injuries
per 1,000 athlete-exposures) and practi-
ces(9.6injuriesper1,000athlete-
exposures) (69,75,76). More striking is
the fact that college football has the
highest rate of sudden death, “cata-
strophic” and “severe” injuries resulting
from player contact, and debilitating in-
juries requiring hospitalization that
occurred during noncontact practices
or supervised strength training or condi-
tioning sessions (23,25,74). In 2012, rep-
resentatives from the NCAA, NATA,
and medical organizations and the
strength and conditioning community
Address correspondence to Tony Caterisano,
tony.caterisano@furman.edu
KEY WORDS:
Preparticipation medical evaluation;
emergency action plan; sudden cardiac
arrest; exertional heat illness; exertional
rhabdomyolysis; transition period;
training volume; training intensity;
work to rest ratio; 50/30/20/10 rule
Copyright ÓNational Strength and Conditioning Association Strength and Conditioning Journal | www.nsca-scj.com 1
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
(including the National Strength and
Conditioning Association [NSCA] and
Collegiate Strength and Conditioning
Coaches Association [CSCCa]) met to
discuss and address the incidence of sud-
den death and debilitating injuries in col-
legiate conditioning sessions. This
meeting resulted in the development,
publication, promotion, and endorse-
ment of best practice recommendations
for strength and conditioning in colle-
giate sports (21). Although indirectly
related, the increasing incidence of
contact-related injuries, specifically spi-
nal cord injuries, concussions, and
chronic traumatic encephalopathy
(15,38,54,56,57), prompted the National
Football League (NFL) and the NCAA
to implement stricter rules governing
gameday competition and increase the
penalties for infractions in an effort to
provide greater oversight and better
safeguard athletes. In 2017, the NCAA
released their “Year-Round Football
Practice Contact Recommendations”
(www.ncaa.org/sport-science-institute/
year-round-football-practice-contact-
recommendations), which placed addi-
tional restrictions on practice sessions,
especially in the preseason, with the
intent of reducing contact-related inju-
ries. The NCAA and several other ath-
letic and medical organizations have also
worked diligently to provide university
athletic programs and their coaching
staffs with guidelines and best practice
recommendations to reduce the inci-
dence of non–contact-related injuries
andsuddendeath(20,23,25,33).For
example, in an effort to reduce the
number of athletes suffering exertional
heat illnesses (EHIs), the NCAA joined
forces with the NATA, the NSCA, the
CSCCa, and several other athletic and
medical organizations to develop guide-
lines for heat acclimatization that limit the
number and intensity of summer practice
sessions and the equipment that can be
worn during those sessions (20,25).
The causes for concern and needs for
intervention are clearly justified. In the
past 20 years (1998–2018), 2 college
football players died from direct con-
tact catastrophic neck injuries suffered
during games—one in 2001 and one in
2017. During the same time frame, 35
football players died during practice or
as a result of participating in preseason
conditioning workouts. Autopsy stud-
ies showed that most of the deaths
were caused by exertional heat stroke
(EHS) or underlying heart conditions
(https://en.wikipedia.org/wiki/List_
of_American_football_players_who_
died_during_their_careers).
In addition to the cases of sudden
death, there has been an alarming
increase in the number of athletes
who have suffered debilitating injuries
(e.g., cardiorespiratory failure, EHIs
and exertional rhabdomyolysis [ER])
during supervised strength and condi-
tioning sessions. The EHI-related death
of a college football player in June of
2018 is a reminder of the importance
of keeping appropriate medical care of
student-athletes at the forefront of
sports and athletic competition. In the
past, the thought that a highly condi-
tioned athlete might have a potentially
fatal heart condition or be susceptible
to sudden death or hospitalization from
a non–contact-related incident might
have been unimaginable. But even one
preventable death is unacceptable, and
35 such events have occurred in the past
2 decades. Although the likelihood of
a college athlete suffering a potentially
fatal event has always been, and
remains, minimal, strength and condi-
tioning professionals must be cognizant
of the fact that the number of deaths
and hospitalizations has increased sig-
nificantly. Attempts to understand the
underlying causes of these tragic events
have rightfully placed the profession
under scrutiny, triggered considerable
public outrage, and resulted in efforts to
publish and implement preparticipation
screening strategies, preparticipation
medical evaluations (PMEs), injury
prevention guidelines for practice ses-
sions and formal competition, and
guidelines for establishing emergency
action plans (EAPs).
Fatalities and catastrophic events in col-
legiate sports continue to occur despite
rule changes to enhance student-athlete
safety and the availability of best practice
recommendations for strength and
conditioning. It is important to note that
conditioning activities often occur dur-
ing sport-specific practice, and such ses-
sions may not be programmed,
implemented, and/or supervised by
a strength and conditioning coach. This
occurs despite previously published and
supported recommendations that all
strength and conditioning sessions
should be developed, implemented,
and under the control of appropriately
trained and certified strength and condi-
tioning staff (21,70). It has also been ex-
pressed that, in some circumstances,
even if the strength and conditioning
coach is directing the conditioning as-
pects of a sports-specific practice, he or
she may be subservient to the sports
coach and as such not have the authority
to determine how the conditioning ses-
sion or activity was planned and/or im-
plemented (70). Although a discussion
on the roles and responsibilities of the
strength and conditioning and sports
coaches is warranted, it is beyond the
scope of this article, but should be part
of the discussion on improving the safety
of student-athletes.
Strength and conditioning sessions
must be appropriately designed and
implemented to reflect the individual
athletes’ current levels of fitness and
fatigue, so as to not induce excessive
exertion. An athlete’s current levels of
fitness and fatigue are dynamic in
nature due to the acute and chronic
effects of sport training, strength and
conditioning, nutrition, hydration,
sleep, and various other factors (e.g.,
medications and supplements).
The incidence of non–contact-related
injuries has increased significantly in
the past decade, particularly in student-
athletes who have recently returned to
training after a period of inactivity (i.e.,
after a vacation between or during aca-
demic terms; January-February and
July-August) when their level of condi-
tioning has likely decreased. According
to the National Center for Catastrophic
Sport Injury Research (NCCSIR)
(https://nccsir.unc.edu/files/2013/10/
NCCSIR-34th-Annual-All-Sport-Report-
1982_2016_FINAL.pdf), the risk of non-
contact injury is significantly greater
CSCCa and NSCA Joint Consensus Guidelines
VOLUME 41 | NUMBER 3 | JUNE 2019
2
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
after periods of inactivity if training
workloads and/or recovery strategies
are not adjusted to reflect athletes’
reduced level of fitness. The NCCSIR
data indicate that almost 60% of non-
contact injuries occur during these pe-
riods in which the athlete is
transitioning back into training follow-
ing a period of inactivity. This increase
in noncontact injuries suggests that
athletes are being exposed to excessive
workloads in the period immediately
after their return to campus, and/or
their training workload is being
increased at a faster rate than is appro-
priate. The risk for serious injury and
death after a period of inactivity is well
documented and was addressed in the
2012 Inter-Association Task Force’s
best practice recommendations (21):
“conditioning periods should be
phased in gradually and progressively
to encourage proper exercise acclima-
tization and to minimize the risk of
adverse effects on health.” The CSCCa
and NSCA continue to support these
best practice recommendations for
strength and conditioning sessions dur-
ing transition periods for collegiate stu-
dent-athletes.
Freshmen student-athletes are a special
population of athletes that are at an
even higher risk for injury because
they transition from the training work-
load demands of high school to colle-
giate sports. Although strength and
conditioning professionals account for
this in their training workload pre-
scription for freshmen athletes, it is
worth reiterating as a reminder, so all
staff associated with the training,
health, and well-being of student-
athletes have an integrated approach
to this population. Transfer and walk-
on student-athletes may also be at
increased risk because they often
approach training with a mentality of
“more is better” in an effort to make the
starting roster over established and/or
scholarship athletes.
The fact that tragic events continue to
occur reflects a need for all sports
coaches, strength and conditioning
staff, medical personnel, and adminis-
trators to be educated about the risks
and potential risks associated with
strength and conditioning training,
particularly during transition periods.
The NCAA and the NATA have pub-
lished and posted a series of journal
and lay articles providing best practice
recommendations for the prevention
and screening, recognition, and treat-
ment of the most common conditions
resulting in sudden death in athletes
(23), guidelines for preseason heat
acclimatization (20), guidelines for pre-
venting EHIs (25), and best practices
for sports medicine management at the
college level (33). Recognizing the
increasing incidence of debilitating
noncontact injuries, it is surprising that
there are presently no published guide-
lines for college coaches and their
strength and conditioning staffs for
training loads to be used for progres-
sive conditioning following inactive pe-
riods (e.g., reporting for conditioning
after a winter or summer break, return-
ing to play after injury). The purpose of
this joint CSCCa/NSCA article is to
focus attention on non–contact-
related injuries and provide guidance
pertaining to the retraining of college
athletes during transition periods. The
recommendations and best practice
guidelines presented are in alignment
with those published previously by
NATA, the NCAA Committee on
Competitive Safeguards and Medical
Aspects of Sports, the NCAA Division
I Football Oversight Committee, and
several other scientific, medical, and
football organizations and are based on
the emerging scientific consensus.
KEY TERMS
For the purposes of these guidelines,
a “severe” injury is defined as resulting
in loss of more than 21 days of partic-
ipation. A “catastrophic” injury is
defined as a permanent disability
injury, serious injury (fractured neck
or serious head injury) although the
athlete has a full recovery, transient
paralysis (athlete has no movement
for a short time but has a complete
recovery), heat stroke due to exercise,
sudden cardiac arrest (SCA)/severe
disruption, or fatality. Injuries are clas-
sified as traumatic or direct/contact-
related and exertional/systemic or
indirect/non–contact-related. Trau-
matic injuries are those which result
directly from participation in the fun-
damental skills of the sport. Exer-
tional/systemic injuries are caused by
system failure (usually cardiac or
thermoregulatory) as a result of exer-
tion while participating in an activity,
or by a complication which was sec-
ondary to a nonfatal injury. These
definitions are supported by previously
published literature (74).
DISCLAIMER
This document is intended to provide
relevant practice parameters for
strength and conditioning professio-
nals to use when performing their
responsibilities in providing services
to athletes or other participants. The
guidelines presented here are based
on published scientific studies, perti-
nent statements from other associa-
tions, analysis of claims and litigation,
and a consensus of expert views. How-
ever, this information is not a substitute
for individualized judgment or inde-
pendent professional advice.
Neither the NSCA, CSCCa, nor the
contributors to this project assume
any duty owed to third parties by
those reading, interpreting, or imple-
menting this information. When ren-
dering services to third parties, these
guidelines cannot be adopted for use
with all participants without exercising
independent judgment and decision-
making based on the strength and con-
ditioning coaches’ individual training,
education, and experience. Further-
more, strength and conditioning prac-
titioners must stay abreast of new
developments in the profession, so that
these guidelines may evolve to meet
particular service needs.
Neither the NSCA, CSCCa, nor the
contributors to this project, by reason
of authorship or publication of this doc-
ument, shall be deemed to be engaged
in practice of any branch of professional
discipline (e.g., medicine, physical ther-
apy, and law) reserved for those
licensed under state law. Strength and
conditioning practitioners using this
Strength and Conditioning Journal | www.nsca-scj.com 3
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
information are encouraged to seek and
obtain such advice, if needed or desired,
from those licensed professionals.
IMPORTANCE OF
PREPARTICIPATION MEDICAL
EVALUATIONS AND
ESTABLISHING EMERGENCY
ACTION PLANS
Most student-athlete deaths are pre-
ventable, and student-athlete health
and safety remains the profession’s top
priority. The National Athletic Trainers’
Association Position Statement: Preventing
Sudden Death in Sports (23) provides
detailed guidelines and recommenda-
tions for the prevention, screening, rec-
ognition, and treatment of the most
common conditions resulting in sudden
death in organized sports. All college-
level coaches, strength and conditioning
staff members, athletic trainers (ATs),
and athletic directors are expected to
know the guidelines and assist in imple-
menting the policies and procedures
outlined in this document. Thoroughly
screening athletes during the PMEs,
creating and implementing EAPs, and
following the guidelines and recom-
mendations outlined by the NCAA
and NATA will lower the likelihood that
a debilitating or fatal incident will occur
and improve the probability of survival
should an event occur. The importance
of adhering to and implementing these
safety practices cannot be overstated.
The NATA position statement empha-
sizes the importance of establishing
and practicing EAPs to appropriately
respond to potentially fatal incidents
(23). EAPs need to be specific to each
athletic facility and venue (e.g., weight
room, locker room, gym, and individ-
ual practice fields). At a minimum, each
EAP should include the following: the
scheduling and training of likely first
responders in first aid, cardiopulmo-
nary resuscitation (CPR), and auto-
mated external defibrillator (AED)
use; the nearest location of necessary
emergency equipment and supplies
(e.g., AEDs, ice chests), and the nearest
location of telephones and the commu-
nication plan to be used to contact
local emergency medical services
(EMS) and pertinent university
personnel (e.g., athletic director). The
EAP should identify by name the per-
son or people responsible for the doc-
umentation of all personnel training,
equipment maintenance, policies and
procedures, actions to be taken during
an emergency, and evaluation of any
response. The EAP should be coordi-
nated with the university’s campus
police and emergency services, the
local EMS agency, and the local hos-
pital. Of greatest importance, EAPs
need to be reviewed, discussed, and
practiced on a regular basis (103).
To provide appropriate care and deter-
mine when emergency treatment is
required, strength and conditioning
professionals need to recognize the
signs and symptoms associated with
a variety of potentially fatal conditions.
The 3 most relevant and potentially
fatal conditions are sudden cardiac
death (SCD), exertional heat stroke
(EHS), and ER, and these will be
described in detail in the following sec-
tions of these guidelines. Immediate
emergency care for the athlete is critical
for each of these 3 conditions since
waiting on an ambulance to arrive
may result in death or permanent dis-
ability. Consistent with NATA and
NCAA recommendations, we urgently
advocate training all college coaches
and strength and conditioning staff
members in first aid, CPR, and AED
use, so that they can assist the certified
ATs onsite in providing treatment until
licensed medical professionals arrive.
Although such care may be inadequate
for some of the conditions described in
these guidelines (e.g., SCD), and saving
an athlete’s life is not the responsibility
of (nor is liability ascribed to) coaches or
strength and conditioning staff mem-
bers, these professionals must make
every reasonable effort to ensure the
health and safety of student-athletes.
SUDDEN CARDIAC DEATH
Pathophysiology. College athletes
are considered to be one of the healthi-
est segments of our society, which is
why the diagnosis of SCA or SCD is
always shocking and has a profound
impact on all of us. Tragically, SCD is
the leading medical cause of death in
NCAA athletes, and a majority (60–
80%) of those deaths occur during or
as a result of participating in noncontact
conditioning sessions (64). The 2 most
common causes are hypertrophic car-
diomyopathy and congenital coronary
anomalies, although there have been
a wide range of postmortem diagnoses
to include Marfan syndrome, myocardi-
tis, valvular heart disease, aortic dissec-
tion, idiopathic left ventricular
hypertrophy, long QT syndrome, Kawa-
saki disease, atherosclerotic coronary
artery disease, and others (6,62–64,91).
Fewer than 20% of SCD cases occur as
a result of direct contact between athletes
during practice sessions (92). The most
common postmortem diagnosis in these
latter cases has been commotio cordis
(“agitation of the heart”), which results
when a traumatic blow to the heart
region induces a fatal ventricular arrhyth-
mia and cardiac arrest. Unfortunately,
autopsy reports do not always accurately
depict the underlying pathological con-
dition, and standardized protocols for
cardiovascular autopsies are needed.
Incidence. Although the incidence of
sudden death due to an underlying car-
diovascular condition is relatively low at
approximately 1:43,000 student-athletes
per year, the rate of SCD is relatively high
(4–6 deaths per year) (60,64,91). When
researchers have analyzed the database
of all NCAA deaths, their findings consis-
tently indicate that males, black athletes,
and basketball players are at a substantially
higher risk, and that SCD is 3–5 times
more likely to occur in black athletes
(59,64,87,91). More research is needed
to determine whether there is a higher
incidence of potentially lethal cardiovas-
cular disease in basketball players or
whether the demands of the sport place
a substantially higher risk on those with
underlying disease. In any event, coaches,
ATs, and other medical personnel need to
make every effort to identify those athletes
at increased risk and improve strategies to
prevent these tragedies.
Symptoms and treatment. In any
athlete who has collapsed in the
absence of contact or trauma,
CSCCa and NSCA Joint Consensus Guidelines
VOLUME 41 | NUMBER 3 | JUNE 2019
4
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
suspicion for SCA should be high until
normal airway, breathing, and circula-
tion are confirmed. Agonal respiration
or gasping for breath should be recog-
nized as a sign of SCA as should
seizure-like activity or jerking shortly
after collapse. If normal breathing and
pulse are absent, EMS should be
alerted immediately and CPR should
be performed in the order of chest
compressions, airway, breathing while
waiting for arrival of the AED, and
stopped only for rhythm analysis and
defibrillation. This should continue
until EMS or other medically certified
providers take over or the (previously
unconscious) athlete starts to move.
Early detection, prompt CPR, rapid
activation of EMS, and early defibrilla-
tion are vital to the athlete’s survival.
For any athlete who has collapsed and
is unresponsive, an AED should be
applied as soon as possible for rhythm
analysis and defibrillation, if indicated.
The greatest factor affecting survival
after SCA is the time from arrest to
defibrillation, with survival rates rang-
ing from 41 to 74% if bystander CPR is
initiated and defibrillation occurs
within 3–5 minutes of collapse
(39,40,116).
Guidelines for prevention. The
PME and traditional physical exami-
nations are essential but have signifi-
cant limitations (88). Improved
screening strategies to include electro-
cardiogram (ECG) and echocardio-
gram (ECHO) need to be considered
for athletes in the highest risk group
(e.g., black athletes with a pre-existing
cardiac condition or family history of
cardiovascular disease). But even these
types of tests are not definitive, and
reports indicate that a substantial num-
ber (up to 80%) of the athletes who
suffered from SCD would likely not
have been reliably diagnosed with
a 12-lead ECG administered during
their preparticipation screening
(87,91). Detection of asymptomatic
cardiac conditions can be improved
when standardized medical history
forms are used to identify and attract
attention to an athlete’s personal or
family history of previous episodes of
exertional syncope (temporary loss of
consciousness caused by a fall in blood
pressure) or exercise intolerance, chest
pain or discomfort, cardiac arrest, or
sudden death of a family member. Con-
tinuing education and gaining a broader
knowledge base about the anatomy
and physiology of the cardiovascular
and pulmonary systems and complica-
tions associated with cardiovascular
disease and cardiac dysfunction
are essential for coaches and condition-
ing staff members as well as ATs and
health care professionals. At minimum,
relevant staff should be aware of
the 12-point preparticipation cardio-
vascular screening guidelines devel-
oped by the American Heart
Association in 2007 for competitive
athletes based on their medical history
and physical examination (See Appen-
dix, Supplemental Digital Content,
http://links.lww.com/SCJ/A259) (89).
EXERTIONAL HEAT ILLNESSES
Pathophysiology. EHIs encompass
a broad spectrum of disorders to inclu-
de minor conditions such as muscle
cramps (heat cramps), heat syncope,
heat exhaustion, and exertional heat
injury, as well as the more severe clinical
condition of EHS. Coaches and ATs
need to be able to distinguish between
the various EHIs to prevent and treat
them appropriately. The risks of EHIs
are ever-present during exercise in the
heat but can also result from exercising
in normal environmental conditions.
They usually occur during the first 5–6
days of unaccustomed heat exposure
(e.g., during preseason conditioning),
before athletes become acclimatized,
blood volume expands, and cardiovascu-
lar adaptations are complete. In 2015, the
NATA and NCAA released consensus
guidelines regarding heat acclimatization
protocols for football athletes at the high
school and college levels (25) (Table 1).
The NATA guidelines emphasize the
importance of the initial conditioning
period without use of protective equip-
ment, followed by a gradual addition of
further equipment. It is extremely impor-
tant for all of us to understand the com-
mon causes and predisposing factors of
EHIs. For example, athletes who have
thesicklecelltraitorwhohaveaprevious
history of EHIs may be more vulnerable
to EHIs, and especially EHS. Imple-
menting strategies to address the com-
mon causes and mitigate their harmful
effects is the best approach to help ath-
letes avoid EHIs or reduce the risk of
subsequent EHIs. The pathophysiology
of EHS is multifactorial and includes the
body’s ability to thermoregulate effi-
ciently and acclimatize to conditioning
in a hot and humid environment. An
athlete’s physical condition, body mass,
state of hydration and electrolyte bal-
ance, and health status are contributing
factors as are certain types of medica-
tions and whether or not the athlete car-
ries the sickle cell trait or has been
a previous “heat casualty” (30,84,104).
EHS is the most severe form of EHI
and is characterized by central nervous
system (CNS) impairment and a core
body temperature greater than 1058F
(or 40.58C) (5,18,47). EHS occur when
the body’s thermoregulatory system be-
comes overwhelmed due to excessive
heat production (i.e., metabolic heat
produced from exercising muscles)
and/or a decrease in the body’s ability
to dissipate heat effectively. Thermoreg-
ulation is a complex interaction of the
CNS, the cardiovascular system, and
the skin to maintain a core temperature
of approximately 98.68F(378C) (120).
The body’s temperature-regulation cen-
ter is located in the hypothalamus and
determines the setpoint for core tem-
perature. The body’s thermoregulatory
system works through a negative feed-
back loop similar to a home heating
system with the hypothalamus serving
as the thermostat. The hypothalamus
receives information regarding core
and surface/skin temperatures from
thermoreceptors and circulating blood.
The hypothalamus then directs thermo-
regulatory mechanisms to adjust
accordingly to initiate the appropriate
heat-transfer responses. If core temper-
ature falls below the normal setpoint
(i.e., 98.68F), peripheral vasoconstriction
and shivering responses increase core
temperature. If core temperature rises
above the normal setpoint, cutaneous
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vasodilation and increased sweating
occur to dissipate heat (120). Core tem-
perature is determined by metabolic
heat production and the transfer of
body heat to and from the surrounding
environment. Metabolic heat produced
by intense exercise may approach 1,000
kcal/h, with more than 90% of the heat
being generated from the exercise-
induced increase in muscle metabolic
activity. If the excess heat load is not
efficiently dissipated away from the
body, core temperature climbs rapidly.
The most efficient mechanism to dissi-
pate heat is the vaporization of sweat
(i.e., evaporation), but this ability rapidly
diminishes when the environmental
humidity level is high or if the athlete
is wearing heavy clothing or equipment.
Although EHS is most likely to occur in
hot and humid weather, it can manifest
with intense exercise in any environ-
mental condition.
Heat acclimatization is an essential
part of the conditioning process and
involves a series of adaptive physiolog-
ical responses to repeated heat expo-
sure over the course of 1–2 weeks.
These adaptations include increases
in plasma/blood volume, stroke vol-
ume, and sweat rate, and decreases in
heart rate, core temperature, skin tem-
perature, and sweat loss (4,108). Ath-
letes should be allowed to acclimatize
to the heat before practicing in pads or
participating in multiple practice ses-
sions per day (20,24). An athlete’s abil-
ity to acclimatize largely depends on
his or her initial level of fitness, as more
highly conditioned athletes acclimatize
more quickly. Trained athletes are
much less susceptible to EHS due to
the training-induced physiological
adaptations described above. Athletes
with a high body mass index (BMI
$30) also generally take longer to
acclimatize and are at increased risk
for EHS because they have a lower
ratio of surface area to mass, and hence,
their bodies are less efficient at dissipat-
ing heat (25,27). Finally, the athlete’s
ability to acclimatize depends largely
on the intensity and frequency of prac-
tice or conditioning sessions. High-
intensity exercise, regardless of
whether it is performed on the practice
field or in the weight room, can elevate
the core temperature of an at-risk ath-
lete (i.e., one who is unfit, overweight,
or unacclimatized) to dangerous levels
in less than 30 minutes. In fact, the
relative intensity of exercise, which is
based in part on the athlete’s fitness
level, has the greatest influence on
the rate of increase in core temperature
and risk for the athlete becoming a heat
casualty (25).
The athlete’s hydration status and cor-
responding electrolyte balance also
Table 1
Recommendations for the prevention of exertional heat illnesses (EHI)
1. Athletes should be screened by physicians to identify those with risk factors for EHI or a history of EHI.
2. Athletes with a history of EHI or susceptible to EHI must be closely monitored.
3. Athletes should monitor their hydration status and replace fluids before, during, and after exercise.
4. Athletes should sleep at least 7 hours per night in a cool environment and eat a balanced diet.
5. Athletes should be discouraged from using dietary supplements or other substances that have a dehydrating effect.
6. Athletes should be acclimatized to the heat gradually over a 7- to 14-day period. Recognizing that the first 2–3 weeks of
preseason practice present the greatest risk, all possible preventive measures should be used during this period.
7. Rest breaks should be planned, and the work-to-rest ratio modified to match environmental conditions and the intensity of the
practice session.
8. A heat acclimatization policy should be developed with guidelines formulated for hot, humid weather conditions based on the
type of activity and wet bulb globe temperature. In stressful environmental conditions, practice sessions should be delayed,
shortened, or rescheduled.
9. The sports medicine staff are required to educate coaches and athletes on preventing and recognizing the signs and symptoms
of EHI. The coaching and support staff must also review and rehearse their emergency action plan (EAP) specific to each training
and practice site and game venue.
10. A cold-water or ice tub and ice towels should always be available to immerse or soak an athlete with suspected EHI. Immediate
whole-body cooling is essential for treating EHI, especially heat stroke.
11. The assessment of rectal temperature is the clinical gold standard for obtaining core body temperature of athletes with EHI. No
other methods of obtaining core body temperature (e.g., oral, tympanic, and temporal) are valid.
12. Certified athletic trainers are the primary providers of medical care for athletes who display signs or symptoms of EHI and have
the authority to restrict an athlete from participating if EHI is suspected.
Reference: National Athletic Trainers’ Association Position Statement: Exertional Heat Illnesses (https://www.nata.org/sites/default/files/
ExternalHeatIllnesses.pdf) (25).
CSCCa and NSCA Joint Consensus Guidelines
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6
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
play significant roles in EHI risk. Inad-
equate fluid intake, excess sweat loss,
vomiting, diarrhea, medications, or
supplements that have a dehydrating
effect (e.g., diuretics, antihistamines,
CNS stimulants, and antidepressants),
and alcohol can all lead to a measurable
fluid deficit. Dehydration of as little as
2% of body weight can negatively
affect an athlete’s performance and
ability to thermoregulate effectively
(26). Caution should be taken to ensure
that athletes arrive at practice euhy-
drated (i.e., having re-established their
weight since the last practice) and have
the opportunity to regularly replace
body water lost during practice. Mea-
suring body weight change before and
after practice sessions and across suc-
cessive days is the preferred method for
monitoring hydration status (120).
Water loss that is not replaced by the
next practice session increases the risk
for EHIs (19,120). During intense exer-
cise in the heat, sweat rates can be as
high as 2 liters per hour (9). Hence, the
rehydration rate may need to be
increased during conditioning sessions
conducted in the heat to minimize fluid
deficits. Electrolyte imbalances, espe-
cially sodium and chloride, also result
from high sweat rates, and athletes
who are not heat acclimatized can lose
significant amounts of these electro-
lytes during conditioning sessions. It
is important to make sure that athletes
are aware that the loss of electrolytes is
equally important as the loss of water,
and that replacing both reduces their
risk of having EHIs or exertional hypo-
natremia (from consuming too much
water) during conditioning sessions.
Finally, athletes who have the sickle
cell trait are at increased risk for
EHS, collapse, and sudden death.
The sickle cell gene is common among
people whose ancestry traces back to
areas of the world where malaria has
been common (e.g., Africa and India)
and is believed to be a genetic adapta-
tion acquired over generations to pro-
tect against malaria (43). One in 12
African Americans carries this gene
compared with 1 in 10,000 Caucasian
Americans. The inherited trait is not
considered a disease (i.e., sickle cell dis-
ease) unless it is inherited from both
parents. However, the sickle cell trait
can result in an abnormality in the
oxygen-carrying protein hemoglobin
found inside red blood cells. This
genetic abnormality leads to the nor-
mal biconcave disk-shaped red blood
cells taking on a rigid, quarter moon or
“sickle” shape under certain circum-
stances. Heat, dehydration, asthma,
exercising at altitude, and inadequate
acclimatization all increase the risk
for medical complications in athletes
with sickle cell trait. Although having
the trait is not a barrier to participating
in competitive sports, athletes with the
trait experience higher rates of physical
distress, including collapse and death
during intense exercise.
Incidence. EHS is the third leading
cause of sport-related death among
college athletes, and football has the
highest incidence rate among all inter-
collegiate sports programs (11). The
number of sports-related EHS deaths
has doubled since 1975 with more
deaths having been reported between
2005 and 2009 than during any 5-year
period of the preceding 30 years
(90,99). The National Center for Cata-
strophic Sports Injury Research data-
base also identified EHIs as the third
most common cause of sports-related
fatalities in high school and college
football players between 1990 and
2010, accounting for 15.6% (n 538)
of reported deaths. Although the inci-
dence of EHS-related death is rela-
tively low among college athletes, the
rate of occurrence of other forms of
EHI remains disturbingly high. In
a more recent study, researchers ana-
lyzed data from 4 NCAA football sea-
sons (2004–2007) and divided the 60
participating universities and colleges
into 5 geographic regions (31). Players
were identified by position, equipment
worn, and the specific type of EHI they
suffered, and the researchers calculated
the number of EHIs reported by ATs or
that caused players to miss practices
between August 1 and September 30
each year. Of the 553 cases of EHI
reported, approximately 74% were
related to exertional heat cramps,
and approximately 26% were a combi-
nation of exertional heat syncope and
heat exhaustion. Fortunately, there
were no cases of EHS reported (31).
The incidence of EHIs was more
common in the Southeast region,
where they accounted for 446 of the
553 cases. It was confirmed that the
incidence of EHIs increases signifi-
cantly in regions with relatively higher
heat indexes, and especially when wet
bulb globe temperature exceeds
82.08F(27.88C). In terms of timing,
heat illness was most common in the
first 3 days of practice, and when
two-a-day practices began on day 6
(of the preseason), there was an
increase in heat illness on days 7 and
8. Collectively, the studies reporting
on the incidence rates of EHIs indi-
cate that the most dangerous time for
football players is during the first 14
days of preseason practice.
Symptoms and treatment. The 2
main diagnostic criteria for EHS are
CNS dysfunction and a core tempera-
ture greater than 1058F (or 40.58C)
(5,19). In addition to the fatally high
core body temperature, the key signs
and symptoms of EHS include physi-
cal collapse, seizure, inability to walk,
hypotension, tachycardia, dizziness,
and vomiting. EHS-related death is
preventable through immediate recog-
nition of symptoms, core (rectal) tem-
perature assessment, and rapid
treatment through cold-water immer-
sion (CWI) (5,23,25). Athletes who
have EHS should be aggressively
cooled, onsite if possible, within the
“golden half hour” after collapse/onset
of symptoms. The goal is to lower the
athlete’s body temperature to 1028F
(38.98C) or less within 30 minutes of
collapse. Morbidity and mortality are
more strongly linked to duration of
hyperthermia, as opposed to the
degree of hyperthermia, hence, the
“cool first, transport second” principle
(22). Immersing the athlete in cold
water is the fastest method for
whole-body cooling and is associated
with the lowest rates of morbidity and
mortality. If CWI is not available, other
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modalities such as wet ice towels
placed over the entire body or
cold-water dousing with or without
fanning may be used but are not as
effective. Policies and procedures for
cooling athletes before transport to
the hospital must be outlined and
explicitly clear in the athletic depart-
ment’s EAP and shared with EMS res-
ponders, so that treatment by all
coaches, trainers, and medical profes-
sionals involved is well-coordinated. If
the athlete’s body temperature is
reduced to 1028F (38.98C) or less
within 30 minutes of symptom onset,
mortality approaches or is actually
zero, and most recover without serious
consequences.
Guidelines for prevention. The
most tragic fact surrounding EHS
deaths in athletes is that the condi-
tion is entirely preventable. At the
same time, the preventable nature of
EHS means there is ample opportu-
nity to prepare for these events and
decrease the likelihood of their
occurrence. The NATA, working in
conjunction with the NCAA and sev-
eral other athletic and medical or-
ganizations, published a position
statement in 2015 with specific
guidelines addressing the prevention,
recognition, and treatment for EHIs
(25). Their recommendations are de-
signed to help strength and condi-
tioning professionals and ATs
maximize the health and safety of
athletes as well as their performance.
However, individual responses to
physiologic stimuli and environmen-
tal conditions vary widely for the rea-
sons described above (e.g., training
status,BMI,andhydrationstatus).
Therefore, the recommendations in
the NATA position statement do
not guarantee full protection from
EHIs but are designed to mitigate
the associated risks. Nonetheless,
their recommendations and preven-
tion strategies should be carefully
considered and implemented by
coaches and ATs as part of an overall
strategy for the prevention and treat-
ment of EHIs.
A recent death during football condi-
tioning drills in 2018 was both tragic
and preventable. Based on the find-
ings reported (https://www.usmd.
edu/newsroom/Walters-Report-to-
USM-Board-of-Regents.pdf ), it was
determined that there was a system-
atic failure at every level of oversight
(coaches, ATs, and university admin-
istrators). The conditioning test that
was conducted (and that resulted in
the student-athlete’s death) was on
the initial day back from a 4-week
break, and there had been no acclima-
tization period before the intense con-
ditioning session; there was no
reported record of individual fitness
assessment by the strength and con-
ditioning staff before the conditioning
session. When the incident occurred,
the coaching and athletic training
staff failed to recognize the severity
of the incident and were reportedly
not familiar with the university’s
EAP; although visibly in distress, the
student-athlete was “walked around
the field for 34 minutes after becom-
ing symptomatic” for EHI; the stu-
dent-athlete’s rectal temperature was
not established nor monitored; the
student-athlete’s vital signs were not
established nor monitored; immedi-
ate and aggressive cooling of the
student-athlete did not occur,
although ice packs and ice towels
were eventually used; cold-water
immersion tubs were available but
were not set-up before the practice
session activity nor were they used
during the incident; the trauma bag
used for football conditioning had to
be retrieved from the training room
for treatment; there was a breakdown
in communication and confusion as to
where staff personnel should meet
EMS upon their arrival; staff person-
nel were not sent or directed to meet
EMS at the predetermined location as
was indicated on the university EAP.
In summary, although the university’s
EAP may have met the intent of es-
tablished guidelines, the university’s
coaching and athletic training staff
and administrators failed to plan,
practice, and implement best practice
guidelines.
EXERTIONAL RHABDOMYOLYSIS
Pathophysiology. Rhabdomyolysis
is a relatively uncommon but poten-
tially fatal condition characterized by
the large-scale breakdown of skeletal
muscle resulting in the release of intra-
cellular contents into the circulatory
system. These cellular contents include
myoglobin and potassium as well as
the enzymes creatine kinase (CK), lac-
tate dehydrogenase, serum glutamic
oxalacetic transaminase, and aldolase
(77,111). Release of these intracellular
components causes electrolyte distur-
bances such as hyperkalemia, which
can lead to nausea, vomiting, mental
confusion, coma, and cardiac arrhyth-
mias. Rhabdomyolysis precipitates
acute kidney injury in 13–67% of
affected individuals and accounts for
5–10% of all cases of acute renal failure
in the United States. Urine may be
dark, often described as tea-colored,
due to the presence of the myoglobin.
Damage to the kidneys may result in
oliguria or absent urine production,
usually 12–24 hours after the initial
muscle damage. These signs and symp-
toms are nonspecific and may not
always be present. An elevated plasma
CK level is the most sensitive labora-
tory marker, indicating muscle injury,
hyperkalemia, compartment syn-
drome, and acute renal failure. These
are the major life-threatening compli-
cations (85,94).
When conditioning exercises or
extreme physical exertion leads to
rhabdomyolysis, it is clinically referred
to as ER. Although ER is the most
common diagnosis, rhabdomyolysis is
also associated with a number of other
conditions to include crush injuries,
hypothermia and hyperthermia, sickle
cell trait (and other ischemic condi-
tions), snake bites, infections, medica-
tions, and inherited conditions (e.g.,
metabolic myopathies) (80). Regard-
less of the cause, the pathophysiology
of muscle cell destruction follows
a common pathway. Damaged muscle
cells are affected by direct cell mem-
brane destruction or by energy deple-
tion (i.e., adenosine triphosphate
[ATP]). When Na
+
/K
+
-ATPase and
CSCCa and NSCA Joint Consensus Guidelines
VOLUME 41 | NUMBER 3 | JUNE 2019
8
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Ca
2+
-ATPase pumps in the cell’s mem-
brane become dysfunctional, excess
calcium begins to accumulate inside
the cell. Excessive intracellular calcium,
in turn, activates proteases and apopto-
sis pathways. Simultaneously, the cell’s
inability to remove reactive oxidative
species leads to mitochondrial dysfunc-
tion (53). Collectively, these conditions
lead to muscle cell death and the
release of the dead cell’s contents into
the circulatory system as described
above. These guidelines will focus on
the prevention, recognition, and treat-
ment of ER.
Incidence. The syndrome of rhabdo-
myolysis was first described in detail
during World War II after the Blitz of
London at which time it was associated
with crush injuries (14). A similar con-
dition was also reported in concentra-
tion camp survivors (34). The first case
of ER was reported in 1960 when 31
US marines were hospitalized after per-
forming an excessive number of squat
jumps (50). More recent military studies
indicate that ER occurs in up to 40% of
individuals undergoing basic training,
usually within the first 6 days. The mil-
itary considers the primary risk factors
for ER to be the trainees’ low levels of
fitness and the introduction of repetitive
exercises (e.g., low-crawling push-ups,
sit-ups, and squats). The military studies
conducted to date report that there is
resolution of myoglobinuria (excess
myoglobin in the blood) within 2 to 3
days, with clinical improvement of most
symptoms within 1 week. Also worth
noting is that 25% of all cases of heat
stroke in the military between 1980 and
2000 were associated with ER, and that
acute renal failure developed in 33% of
those individuals (https://health.mil/
News/Gallery/Infographics/2017/04/
04/Update-Exertional-Rhabdomyolysis-
Active-Component-US-Armed-Forces-
2012-2016) (1,7).
Other than military recruits, college
athletes returning from a period of inac-
tivity are the group most susceptible to
developing ER (1,3,7,44,46,82,98,102).
It has also been reported in bodybuild-
ers, marathon runners, and recreational
weight trainers who engage in high-
volume training programs or hybrid
workouts that incorporate resistance
training circuits with sprints
(12,16,28,48,49,110,113). Workouts that
emphasize eccentric muscle contrac-
tions also seem to place athletes at
a higher level of risk for ER (29,79,121).
One of the most publicized cases to
date of ER occurred in January 2011
(45,128). Two days after a 3-week win-
ter break, the football team started an
intense strength training program that
included barbell snatches, pull-ups,
dumbbell rows, and weighted sled
drills. The most challenging task in
the workout was the assignment for
athletes to perform 100 back squats
with 50% of their 1 repetition maxi-
mum (1RM) as measured at their last
assessment. Although the times for
completing the squat workout were
not posted, the athletes were timed
and may have viewed it as a competi-
tion. Within 1 week, 13 football players
were hospitalized with ER (their CK
levels ranged from 96,987 to 331,044
IU/L, whereas normal levels are
between 22-198 IU/L). Although
some of the athletes developed tran-
sient renal dysfunction, none devel-
oped compartment syndrome, and all
were discharged within a few days as
their symptoms subsided. This one
event led to the inclusion of an oblig-
atory acclimatization period during
the initial days of preseason train-
ing (www.iowaregents.edu/media/
cms/finalreportonrhabdoincident-
pdf1A6655AB.pdf).
In the following year (2012), 5 football
players were hospitalized after a similar
squat workout, with one athlete suffer-
ing compartment syndrome in both
quadriceps (109). In 2017, a strength
and conditioning coach was sus-
pended, and the university issued an
apology on behalf of its athletic depart-
ment after 3 football players were hos-
pitalized after enduring a series of
grueling strength and conditioning
workouts. Numerous athletes in
NCAA programs other than football
have been hospitalized for ER. In
2007, for example, the new swim coach
had his athletes perform as many push-
ups as possible in a minute followed by
as many free-standing squats in
a minute, repeating the cycle for 10 mi-
nutes. The conditioning session was
followed by a strenuous swim workout,
and the entire regimen was repeated
the next 2 days. Not surprisingly, 7 of
the swimmers (males and females)
were hospitalized for ER. In 2011, it
was 3 members of a university wom-
en’s soccer team; in 2012, it was 6
women’s lacrosse players; and in
2016, it was 8 volleyball players. Col-
lege ROTC cadets have also been
affected. In the most prominent case
involving ROTC cadets, 11 of 44
(25%) were hospitalized for ER after
participating in a timed “extreme con-
ditioning program” that consisted of
a mile run, 100 pull-ups, 200 push-
ups, 300 free-standing squats, and the
completion of another mile run (113).
Collectively, the military studies and
those involving college athletes indi-
cate that specific factors increase the
risk of ER to include hyperthermia,
hydration status, whether the athlete
carries the sickle cell trait, and the
types of supplements the athlete may
be ingesting (www.health.mil/News/
Gallery/Infographics/2017/04/04/
Update-Exertional-Rhabdomyolysis-
Active-Component-US-Armed-Forces-
2012-2016) (3,44,102). It should not be
surprising that ER is highly correlated
with EHI as both conditions can result
when blood flow is shunted away from
exercising skeletal muscle and toward
the surface of the skin to dissipate heat
as the body attempts to thermoregu-
late (16). Athletes who have the sickle
cell trait may also be at increased risk for
ER as the odd-shaped sickle red blood
cells have a tendency to block small
vessels, leading to ischemic rhabdo-
myolysis (43). Consequently, athletes
who carry the sickle cell trait and expe-
rience exertional sickling may be at
a higher risk of death from ER than
those without the trait (3,44,61,65,125).
Symptoms and treatment.
Although mild cases may not cause
symptoms, most athletes with ER
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Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
experience a common set of com-
plaints (115,136). Most symptoms
appear within hours to days after the
condition develops. Common symp-
toms include muscle pain that is often
aching and throbbing, muscle weak-
ness, muscle swelling or inflammation,
dark- or cola- or tea-colored urine, gen-
eral exhaustion or fatigue, irregular
heartbeat, dizziness, light-headed, or
feeling faint, confusion or disorienta-
tion, nausea or vomiting. A secondary
condition called compartment syn-
drome may occur after intravenous
(IV) fluid is administered. This second-
ary condition causes the compression
of nerves, blood vessels, and muscle,
and can result in additional tissue dam-
age and problems with blood flow.
Medical attention should be sought
any time an athlete presents with
symptoms associated with ER.
Untreated cases can become serious
and may cause life-threatening compli-
cations such as kidney failure or liver
problems. Blood tests for CK, a product
of muscle breakdown, and urine tests
for myoglobin can help diagnose rhab-
domyolysis (although in half of the ath-
letes with ER, the myoglobin is
negative). Additional tests may be
administered to rule out other prob-
lems or be used to check for
complications.
Treatment depends on the severity of
the case, symptoms, and presence of
additional health complications that
may increase the risk of kidney damage.
In severe cases, kidney damage can be
irreversible without early treatment.
Hence, early diagnosis and treatment
are critical for a successful recovery.
Athletes who develop the symptoms
associated with ER need to be quickly
admitted to the hospital. Treatment
with IV fluids helps maintain urine pro-
duction and prevent kidney failure.
Large volumes of water are often
administered to rehydrate the body
and flush out any myoglobin. Dialysis
may be necessary to help the kidneys
filter waste products while they are
recovering. Management of electrolyte
abnormalities (e.g., potassium, calcium,
and phosphorus) helps protect the
heart and other vital organs. In the
event that compartment syndrome
threatens muscle death or nerve dam-
age, a surgical procedure (fasciotomy)
can be used to relieve tension or pres-
sure and loss of circulation.
Guidelines for prevention. All the
studies on ER referenced above share
a common set of core characteristics.
All involve athletes or military train-
ees/cadets performing a high volume
of submaximal resistance exercises or
body weight exercises (push-ups,
pull-ups, etc.) to fatigue and/or in
a limited time frame. Most cases of
ER cited above occur when an individ-
ual is exposed to a novel workout reg-
imen or following a period of
detraining (i.e., returning from winter
or summer break). Many occur in hot
environmental conditions or in train-
ing facilities that have poor climate
control. Athletes who are dehydrated
and/or carry the sickle cell trait are at
increased risk. Finally, most cases
involving college athletes were caused
by a new or an overzealous coach
using exercise as punishment or trying
to build “mental toughness” (46,109).
More often than not, it is a combination
of these factors that results in athletes
being hospitalized for rhabdomyolysis.
To maximize prevention strategies,
every strength and conditioning coach
and his or her staff members, and all
ATs should be educated about ER, the
causes and symptoms, and engage in
best practices for preventing it.
RETURN TO TRAINING DURING
TRANSITION PERIODS
In February 2018, the NCAA Chief
Medical Officer, Brian Hainline, issued
a set of guidelines recognizing that pe-
riods where athletes have undergone
significant detraining increase the like-
lihood of injury resulting from training.
The guidelines recommend that dur-
ing this time as athletes transition back
into training, workouts should have
lower work-to-rest ratios and progress
gradually up to full intensity. In addi-
tion, workouts should be documented
and made available for administra-
tive staff.
Certainly, one of the challenges during
the training of athletes is the design
and application of the appropriate
exercise, volume, intensity, and rest
that will maximize performance
enhancement while minimizing the
likelihood of exercise-induced injuries.
This includes the identification of
symptoms specific to ER, EHIs, and
cardiac issues due to pre-existing
health conditions and genetic factors,
as mentioned earlier in this article. It
also requires clear, standardized train-
ing guidelines for new, returning, and
post-ER/EHI athletes (122,133).
Although no preventive intervention
will eliminate all risk, following a stan-
dardized plan can minimize the risk
inherent during transition periods.
The mission of this CSCCa/NSCA
Joint Committee is to provide
evidence-based guidelines for training
to decrease the risk of ER, EHIs, and
cardiovascular-related incidents fol-
lowing inactive periods. These guide-
lines should also apply to ‘optional’
practices and workouts.
There are 3 scenarios that need to be
considered following a period of inac-
tivity. The first scenario is for returning
athletes who have experienced a 2-
week break or longer or for student-
athletes who are beginning under
a new head sport coach. It should be
noted that these programming guide-
lines should be applied to student-
athletes in all sports. The second sce-
nario is for new athletes such as fresh-
man or transfer student-athletes that
are coming off a period of inactivity,
or all student-athletes who are begin-
ning under a new head strength and
conditioning coach. The third scenario
is for student-athletes returning to
training after an incident of ER or
EHI. This final scenario will involve
a 6- to 8-week rehabilitation program
(117) to provide the reintroduction and
progression of physical stress to the
student-athlete.
The Joint Committee recommends
that prescription of conditioning drills
after the period of inactivity follows
a schedule of reduced volume or work-
load adhering to the 50/30/20/10 rules
CSCCa and NSCA Joint Consensus Guidelines
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Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
for a 2-week period (for returning
athletes/new head sport coach), or
a 4-week period (for new athletes/
new head strength and conditioning
coach). These are summarized in
Table2.Theserulesprovidearecom-
mended percentage weekly reduc-
tion of volumes and/or workloads
for conditioning and testing in the
first 2–4 weeks of return to training,
basedontheuppermostvolumeof
the conditioning program. This con-
ditioning program should be submit-
tedtoanappropriatesport
administrator before the return to
training. For example, with a new
athlete entering the program, the
conditioning volume for the first
week would be initially reduced by
at least 50% of the uppermost condi-
tioning volume on file, and by 30, 20,
and 10% in the following 3 weeks,
respectively, with a 1:4 or greater
work:rest ratio (W:R) in the first
week, and a 1:3 W:R or greater in
the second week (21). For these
new athletes, a conditioning test
must be completed on the first day
of training and should be performed
at 50% of the test volume on file with
the administrator with a 1:4 or
greater W:R. In the case of an athlete
returning from a period of inactivity
of 2 weeks or more, the reduction in
conditioning volume would be at
least 50% in the first week, and then
30% in the second week, returning to
standard loads thereafter. Any testing
would be performed at a 20% reduc-
tion in the workload (through reduc-
tions in volume, intensity, or rest
time) if completed in the first week
and a 10% reduction if completed in
the second week. Furthermore, the
FIT rule (frequency, intensity vol-
ume, and time of rest interval) out-
lines the recommendations for
resistance training during these tran-
sition periods. The following para-
graphs and associated tables
describe the application of these con-
cepts. Note that each coach may
decide to reduce the volume and/or
intensity by a greater amount based
on environmental conditions and/or
individual athletes’ needs.
The 50/30/20/10 rules and the FIT
rule will ensure that strength and con-
ditioning coaches are evaluating their
programs to be certain that student-
athletes return to training in a safe,
effective manner. These guidelines are
meant to protect student-athletes in all
sports, but also strength and condition-
ing coaches and universities without
stifling the expertise, autonomy, and
creativity of the strength and condi-
tioning coach. These rules, used during
the first 2–4 weeks of mandatory train-
ing after a period of inactivity, give
every strength and conditioning coach
a standardized roadmap, much like
ATs have with the concussion proto-
col. The recommendations are based
on research on detraining showing that
reduced activity can lead to decreases
in muscle strength (2,32,59,131), aero-
bic capacity (73,127,130,131), anaero-
bic capacity (73,93,137), and induce
skeletal muscle atrophy
(32,59,78,100,101,132). These decre-
ments are seen in a wide range of ages
(2,67,78,105,135), potentially inducing
injury or illness. Although some studies
Table 2
Overview of recommended guidelines for training after transition periods
Status Conditioning activities Testing Weight training Plyometrics
Midseason
athletes
Conditioning program on file with appropriate sport administrator
Returning
athletes
or new
sport
coach
50/30% weekly reduction
from max conditioning
volume on file over 2
weeks. Even
distribution per week.
20/10% weekly reduction in
workload (volume,
intensity, or rest time) for
any tests over 2 weeks.
FIT rule to guide
volume, intensity, and
W:R ratio over 2
weeks. IRV between
11 and 30 (Tables 7
and 8).
,70 foot contacts per session
first week, 1:4 W:R. ,100
foot contacts/session, 1:3
W:R second week. Intensity
as appropriate.
New
athletes
or new
head
strength
coach
50/30/20/10% weekly
reduction from max
conditioning volume
on file over 4 weeks.
Even distribution per
week.
50% reduction in testing
volume, completed on first
day. 30/20/10% weekly
reduction in test volume if
repeated in following 3
weeks.
FIT rule to guide
volume, intensity, and
W:R ratio over 2
weeks. IRV between
11 and 30 (Tables 7
and 8).
,70 foot contacts per session
first week, 1:4 W:R. ,100
foot contacts/session, 1:3
W:R second week. Intensity
as appropriate.
Return
from ER,
EHI, or
long
inactivity
50/30/20/10% weekly
reduction from max
conditioning volume
on file over 4 weeks.
Even distribution per
week.
50% reduction in testing
volume, completed on first
day. 30/20/10% weekly
reduction in test volume if
repeated in following
weeks.
Gradual increase over 5
weeks (Table 9),
followed by FIT rule
limitations for 1 week.
,80 foot contacts per session
at low intensity, 1–2
sessions per week, gradual
increase in foot contacts
and intensity over 5 weeks
(Table 10)
EHI 5exertional heat illness; ER 5exertional rhabdomyolysis; IRV 5intensity relative volume.
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indicate that previously trained athletes
undergoing short periods of detraining
(1–4 weeks) do not exhibit a large de-
training effect (51,59,72,78,106,124),
the preponderance of evidence sup-
ports at least a brief period of lower
workload to offset detraining effects
that might appear, especially with lon-
ger periods of inactivity.
RETURN TO TRAINING 50/30/20/10
CONDITIONING AND TESTING
RULE FOR RETURNING ATHLETES
OR PROGRAMS WITH A NEW
HEAD SPORT COACH
Retraining following short detraining
periods can induce restorative im-
provements in aerobic and anaerobic
performances (73,100,127), as well as
muscular strength and hypertrophy
(67,105,106,132,134). Retraining is
especially effective for developing mus-
cle strength and hypertrophy as there
is evidence that the myonuclei ob-
tained during hypertrophy are main-
tained even during extreme atrophy
(13,55). Myonuclei serve as required
machinery for muscle growth, thus
a greater number of myonuclei facili-
tate the restoration of skeletal muscle
mass lost during inactive periods. Fur-
thermore, studies involving humans
(8,41,52) and rats (10) have shown ini-
tial training and/or retraining enhances
myocardial morphology and function.
Therefore, a 2-week transition period
of decreased workload should be suffi-
cient to allow athletes to fully recover
any loss in strength or metabolic capa-
bilities following inactivity. However,
extra caution should be exercised when
assigning volume loads for returning
athletes. Therefore, the Joint Commit-
tee recommends that weekly condi-
tioning volume be reduced by 50%
from the uppermost volume on file in
week 1 with a 1:4 or greater W:R and
30% in week 2 with a 1:3 or greater
W:R. For example, if the total condi-
tioning volume for football athletes is
4,000 yards per week, this should be
reduced to no more than 2,000 yards
in the first week and a maximum of
2,800 yards in the second week during
the transition period. The daily volume
must be reasonably distributed over 2
or more days per week to avoid injury.
If conditioning testing is completed,
then the workload (whether through
intensity, volume, rest time, or a com-
bination) should be reduced by 20% in
the first week and 10% in the second
week. Because of the reduction in
workload, there is no mandate to
change the W:R for these testing ses-
sions. Tables 3–6 outline examples of
application of the rules for testing of
returning athletes. For example, the
application of a standard repeat sprint
ability (RSA) test with duration of 6–8
seconds should consist of 45-second
rests between bouts, and in the case
of team-based field sports, should not
exceed a weekly sprint volume of 285
yards in the first 2 weeks of condition-
ing (66). The 20% and 10% reductions
would result in a sprint volume of
approximately 230 and 260 yards,
respectively, before reaching the 285
yards (Table 3). Exercise-induced mus-
cle damage in the form of delayed-
onset muscle soreness has been shown
to result in decreased performance in
RSA (37), and this is taken into account
with the reduced workload in the first 2
weeks under these guidelines. Addi-
tional examples of options for reduc-
tions in testing workload can be seen
in Tables 4–6. The standards for these
tests may vary from program to pro-
gram but should fall in line with estab-
lished standards by sport and skill level
(e.g., Division I athlete). Standardized
tests and norms for different athletes
can be found in the NSCA’s Guide to
Tests and Assessments (97). Coaches
should apply these changes in inten-
sity, volume, or both to the standards
they have set for their given program as
maximal capacity expected of the ath-
lete for each conditioning drill.
RETURN TO TRAINING 50/30/20/10
CONDITIONING RULE FOR NEW
ATHLETES, OR PROGRAMS WITH
A NEW HEAD STRENGTH AND
CONDITIONING COACH
On entry into a program, new athletes
(freshmen or transfers) may not be
physiologically prepared for the de-
mands of testing or training after
a period of detraining. Two to 4 weeks
of detraining can result in decreases in
aerobic and anaerobic performance
(73) with associated decreases in cap-
illary density and blood volume (100).
Likewise, brief detraining periods result
in only small decreases to strength (71).
However, longer periods of inactivity
(including a lack of in-season training)
result in much larger strength losses
(58,83,123), and thus, the retraining
process must be undertaken with more
caution. Understanding timelines asso-
ciated with the degree of detraining
and retraining provide a justification
for reduced volume and/or intensity
of training when embarking on a new
program or resuming training during
transition periods.
Because the detraining period and
physiological conditioning will vary
from athlete to athlete and will be
especially unknown for athletes with
no previous history or test results in
the program, the Joint Committee
mandates a safety precaution consist-
ing of a minimum 50% reduction in
volume from the uppermost condi-
tioning volume on file in week 1, and
30, 20, and 10% reduction in the fol-
lowing 3 weeks, respectively. A 1:4 or
greater W:R should be used for week
1, and a 1:3 or greater W:R for week 2.
For these new athletes, conditioning
Table 3
Reductions in workload for team-based field sport repeat sprint ability (RSA)
test
Week (reduction %) Volume Intensity (s) Rest time (s)
Week 1 volume (20%) 230 yds 6–8 45
Week 2 volume (10%) 260 yds 6–8 45
Week 3 volume (normal) 285 yds 6–8 45
CSCCa and NSCA Joint Consensus Guidelines
VOLUME 41 | NUMBER 3 | JUNE 2019
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testing must be completed on the first
day of return to training and should be
performed at 50% of the standard vol-
ume of the test on file with the admin-
istrator, using 1:4 or greater W:R.
Although not mandatory, testing may
be repeated but should follow the rule
for conditioning activities, with a 30/
20/10% weekly reduction in volume at
standard intensities and rest times.
THE 50/30/20/10 CONDITIONING
RULE FOR RETURN TO TRAINING
AFTER LONG INACTIVITY,
EXERTIONAL HEAT ILLNESS, OR
EXERTIONAL RHABDOMYOLYSIS
The return to training recommendations
that have been previously outlined apply
to student-athletes who are free of
a recent ER or EHI incident that pre-
vented them from training, but for
student-athletes who have suffered seri-
ous injury, EHI, or ER, the recovery is
more difficult. The time frame a student-
athlete may be removed from training
and practices may vary, but once he or
she is released from hospitalized medical
care, the return to training process can
begin. Schleich et al. (122) outlined a 4-
phase approach with phase I being 2
weeks of activities of daily living only,
while a 1-week phase II begins the use
of aquatic exercises and warm-up exer-
cises. Phase III adds resistance exercises
performed with body weight only, core
training, stretching, and addition of sta-
tionarycyclingonthefourthday.Finally,
phase IV introduces resistance training
with 20–25% of estimated 1RM, agility
exercises and running (122). These 4
phases follow the progression of physical
function after injury as outlined by Cart-
wright and Pitney (17) that includes an 8-
step plan of (a) mobility, (b) flexibility, (c)
proprioception, (d) muscular strength,
(e) muscular endurance, (f) muscular
power, (g) cardiovascular endurance,
and (h) sport-specific function. Once
the student-athlete completes the 4
phases and has been released to the
strength and conditioning coach, it is
the coach’s responsibility to continue
theprogression.Themonitoringofthe
student-athlete’s recovery and program
effectiveness during the return to training
is critical for effective physical adapta-
tions (118). The strength and condition-
ing coach will continue with the gradual
increase in volume of conditioning drills
and weight training following
a minimum 50/30/20/10% reduction
in volume over a 4-week period before
a return to regular training. Overall, this
return to training for a student-athlete
after release from the medical staff may
be a 6- to 8-week period to provide ade-
quate time to build a strength and con-
ditioning base (117). The progression of
conditioning and weight training must
take into account managing of training
load, recovery, and fatigue to reduce the
chance of reinjury (129), more specifi-
cally a reoccurrence of ER and EHI.
FIT RULE FOR WEIGHT TRAINING
ACTIVITY
Return to weight training during a tran-
sition period following a period of active
rest or minimal training requires atten-
tion to the physical stress applied to
incoming and returning athletes. In the
first 2 weeks, the strength and condition-
ing coach should be cognizant of the
type of training stimulus, volume, inten-
sity, frequency, and the potential risk for
each student-athlete. The FIT rule is de-
signed to ensure that frequency, intensity
relative volume (IRV), and time of rest
interval are appropriately administered
to minimize the chance of severe muscle
damage.
Frequency is defined as the number of
training sessions completed per week
for a specific muscle group or move-
ment type (95). For example, the
student-athlete might train a total of 5
days in the week, but only train lower
body for 3 days, so the frequency for
lower-body movements would be 3.
The strength and conditioning coach
must use discretion on how to distribute
training exercises to meet the frequency
parameter for each muscle group or
movement type. It is recommended that
frequency not exceed 3 days in the first
week following a period of inactivity and
no more than 4 days in the second week.
IRV is a derivation of volume load that
includes the %1RM (95,107,138) and is
calculated with the following equation:
Sets 3Reps 3%1RM as a decimal
5IRV units:
The strength and conditioning
coach has a wide range of set and
Table 4
Options for reductions in workload for 110-yard sprint test for American
football (101)
Week Options for reduction (%) Repetitions Intensity (s) Rest time (s)
Week
1
Volume (20%) 13 15 45
Intensity (20%) 16 18 45
Rest time (20%) 16 15 54
Intensity (10%) and rest time
(10%)
16 17 50
Week
2
Volume (10%) 14 15 45
Intensity (10%) 16 17 45
Rest time (10%) 16 15 50
Intensity (5%) and rest time (5%) 16 16 47
Week
3
Normal 16 15 45
Example provided is for skill positions. Baseline intensity for linemen is 18 seconds.
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rep combinations or manipulations
that can be used in his or her stu-
dent-athlete’s training program. A sys-
tematic review by McMaster et al. (95)
indicates that IRVs between 11 and 20
provide the greatest strength increases,
whereas IRVs between 21 and 30 pro-
duce strength increases that are some-
what lower. An IRV below 11 may not
be adequate to improve strength.
Therefore, the Joint Committee recom-
mends an IRV between 11 and 30 for
a specific muscle group or movement
type. IRVs of greater than 30 are con-
traindicated in the 2 weeks following
period of inactivity. Table 7 provides
practical examples of how to apply
IRV to a weight training program. Each
strength and conditioning coach will
use his or her own judgment regarding
limitations on the return to training
program. The options presented are
meant to illustrate the freedom for var-
ious styles of programming within the
FIT rule.
Time of rest interval, also known as
work-to-rest ratio (W:R), is a vital
component that must be considered
in reducing the risk of ER in student-
athletes. As described earlier, ER is
often related to high volume training
programs or hybrid workouts that
incorporate resistance training circuits
with sprints. In most of the cases of ER
in student-athletes referenced earlier,
student-athletes were subjected to
a W:R of 1:1 or less. Additional rest
time, however, is necessary as it allows
the cardiorespiratory and circulatory
system to deliver oxygen to muscles
and reduce the potential for muscle
cell damage. Consequently, based on
the W:R guidelines provided in the
Inter-Association Task Force for Preventing
Sudden Death in Collegiate Conditioning
Sessions, the Joint Committee recom-
mends that all weight training activity
use a 1:4 or greater W:R during week 1
and a 1:3 or greater W:R during week 2
(21). The rest provided during more
traditional strength training will be
much greater, but this minimum stan-
dard will provide protection for
student-athletes engaging in high-
volume/high-intensity training ses-
sions. The Joint Committee recom-
mends that strength and conditioning
coaches follow the parameters outlined
by the FIT rule in Table 8 to further
protect student-athletes against the
increased risk of ER during their return
to regular training during transition
periods. After reviewing the informa-
tion in Table 8, coaches should begin
to evaluate the periodized lifts in their
current programs, which they may
find already fall within the designated
guidelines.
TRIPLE EXTENSION EXERCISES
Triple extension exercises (e.g.,
cleans, snatches, etc.) are unique in
their demands on the body.
Although there has been no known
research on volume limits for triple
extension exercises, and although no
cases of ER have been reported due
to a high volume of loaded triple
extension exercises, precautions
should still be taken to avoid unnec-
essary risk. Strength and condition-
ing coaches who do use triple
extension exercises in their student-
athletes’ programs should subscribe
to best practice protocols in terms of
volume,intensity,andW:Rratio.
Basedonbestpractices,theJoint
Committee recommends that for all
triple extension exercises, IRV
should not exceed 25 units in the first
2 weeks during transition periods. In
addition, daily total volume as
defined by sets 3repetitions in these
exercises should not exceed 50 rep-
etitions while weekly total volume
should not exceed 125 repetitions
in week 1 and 150 repetitions in
week 2.
PLYOMETRIC EXERCISES
Although loaded triple extension exer-
cises are traditionally used for develop-
ing power, many programs use
plyometric exercise as the primary
method of training to improve power
in student-athletes. These exercises
should also be monitored and docu-
mented by the strength and condition-
ing coach in the first 2 weeks following
periods of inactivity. Applying the FIT
rule to plyometric exercise may be
more challenging because of differen-
ces in body mass and relative strength
levels, but an estimate could be ob-
tained using the 50/30/20/10 rule.
For example, based on previously
accepted volume recommendations of
120–140 foot contacts for in-season
Table 5
Options for reductions in workload for 60-yard shuttle test for collegiate
basketball: 18 total reps divided among 3–4 sets, 12 seconds to complete, 45
seconds rest between reps, and 90 seconds between sets
Week Options for reduction (%) Repetitions Intensity (s) Rest time (s)
Week
1
Volume (20%) 14 12 45
Intensity (20%) 18 14 45
Rest time (20%) 18 12 54
Intensity (10%) and rest time
(10%)
18 13 50
Week
2
Volume (10%) 16 12 45
Intensity (10%) 18 13 45
Rest time (10%) 18 12 50
Intensity (5%) and rest time (5%) 18 13 47
Week
3
Normal 18 12 45
CSCCa and NSCA Joint Consensus Guidelines
VOLUME 41 | NUMBER 3 | JUNE 2019
14
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
athletes (112), plyometric workouts in
the first 2 weeks should not exceed 70-
foot contacts in week 1 and 100 in
week 2 for the average-sized athlete,
using exercises of an intensity deter-
mined by the strength and condition-
ing coach. This should be modified for
athletes with higher body mass or ath-
letes with lower than average strength
levels, at the strength and conditioning
coach’s discretion. Returning athletes
can engage in normal volumes in
weeks 3 and 4 while new athletes
should follow a 20/10% reduction dur-
ing that time. The time of rest interval
for plyometric exercises should have
a 1:4 or greater W:R in week 1 and
a 1:3 or greater W:R in week 2.
ADDITIONAL CONSIDERATIONS
FOR WEIGHT TRAINING RETURN
FROM EXERTIONAL
RHABDOMYOLYSIS AND
EXERTIONAL HEAT ILLNESSES
Testing the student-athlete’s muscular
strength and power levels after ER and
EHIs requires attention to the eccen-
tric muscle contractions as they are
precursors to ER in particular (42).
Before unrestricted weight and power
training, student-athletes need to first
return to baseline muscular strength or
power levels. This can be based on test
results for the athlete before the injury.
Strength and power levels vary per
sport, athlete position, training age,
and previous injury history, thus
requiring the strength and conditioning
coach to individualize testing for these
student-athletes. Therefore, the initial
tests in the weight training program
should assess all muscle groups that
will be tested on unrestricted return
to training. The tests for strength and
power would count as a training ses-
sion in the first week because the load-
ing will be stressful on the recovering
muscles. After a hiatus from strength
and conditioning as result of ER/
EHI, the inclusion of weight training
that emphasizes or incorporates an
eccentric muscular contraction must
be gradually reintroduced because
eccentric training has been accepted
as a mechanism that increases the
chance of muscular damage that may
result in temporary decreases in phys-
ical performance (37,81,96,119). The
appropriate and consistent application
of eccentric training, however, can
increase physical performance
(96,139) and should be included as
soon as tolerated by the athlete. These
student-athletes returning to training
after ER or EHIs should be treated
as beginning athletes that have no
experience with any weight training
activities and should follow previously
described guidelines (126). After the
testing sessions, frequency should
begin with only 2 weight training ses-
sions in the first and possibly second
week, progressing to 3 times a week
(126). If muscle soreness dissipates
Table 6
Options for reductions in workload for half gasser test for collegiate softball: 20 reps, 106 yards per rep (sprint distance is
53 yards one direction), 19 seconds to complete 1-repetition, 1-minute rest
Week Options for reduction (%) Repetitions (yards) Intensity (s) Rest time
Week 1 Volume (20%) 16 (1,696) 19 1 min
Intensity (20%) 20 (2,120) 23 1 min
Rest time (20%) 20 (2,120) 19 1 min 12 s
Intensity (10%) and rest time (10%) 20 (2,120) 21 1 min 6 s
Week 2 Volume (10%) 18 (1,908) 19 1 min
Intensity (10%) 20 (2,120) 21 1 min
Rest time (10%) 20 (2,120) 19 1 min 6 s
Intensity (5%) and rest time (5%) 20 (2,120) 20 1 min 3 s
Week 3 Normal 20 (2,120) 19 1 min
Table 7
Intensity relative volume (IRV) practical examples in the first 2 weeks after
a transitional period
Example Sets Repetitions % 1RM IRV units Range level
1 3 12 0.65 23.4 Acceptable
2 5 10 0.60 30.0 Acceptable
3 5 8 0.70 28 Acceptable
4 8 5 0.75 30.0 Acceptable
5 10 10 0.50 50 Much too high
Includes warm-up sets.
RM 5repetition maximum.
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within 48 hours after the end of the
weight training session, then higher
training frequency may be included.
Rest periods between sets in these first
2 weeks of training after ER should be
at minimum 5 minutes for strength and
power development (126). Table 9 pro-
vides a possible progression for
student-athletes returning from ER.
The decision to include plyometrics,
speed, and agility exercises should
meet the criteria previously established
for the beginner level inclusion for
these activities (e.g., back squatting
1.5 times body weight (35,112)). For
student-athletes returning from ER/
EHIs, plyometric exercise volume
should be no more than 70-foot con-
tacts in the first week and gradually
increased to 100-foot contacts depen-
dent on muscle soreness (Table 10)
(112). The intensity classifications as
described by Potach and Chu (112) will
allow strength and conditioning
coaches to appropriately adjust
intensity, as higher intensity exercises
usually involve significant eccentric
activity. Before the addition of any
plyometric exercises, student-athletes
should be free from muscle soreness
after linear sprint sessions. The
strength and conditioning coach’s
decision to include plyometric and
agility exercises, and the rate progres-
sion of such, should be carefully con-
sidered for each student-athlete and
may not coincide with their weight
training regimen. Once linear sprints
can be performed without increased
muscle soreness and the student-
athlete is able to perform them at their
previous training volumes, then agility
and change of direction drills can be
added. The FIT rule will be applied
to these student-athletes only after
they have achieved baseline levels for
all strength and power tests.
The progression of a strength and con-
ditioning program for a student-athlete
recovering from ER does not follow
the same guidelines as those of
student-athletes returning from active
rest period. After 14 days or more of
detraining (with no activity as could be
the case for an athlete returning from
ER), athletes may demonstrate decre-
ments in strength performance,
whereas active rest periods of adequate
training volume or intensity may pre-
vent a decrement (68,71). For those
recovering from ER, physical perfor-
mance increases should follow the
guidelines outlined by Schleich et al.
(122) and described earlier in this doc-
ument, or an equivalent protocol
deemed safe by the sports medicine
staff. Once this protocol is completed
and the athlete is released by the sports
medicine staff, the 50/30/20/10 rule
and FIT rule should be followed.
Student-athletes returning from ER
or EHIs will need continued monitor-
ing for injury reoccurrence and may
require a greater amount of time to
develop a level of physical fitness that
Table 9
Suggested weight training progression for return to training after exertional rhabdomyolysis
Week Sets Set volume (repetitions) Intensity (% of 1RM) Rest time (min) Frequency (d)
1 1–2 5–6 Light (,75%) 5 1–2
2 2–3 5–8 Light (,75%) 3–5 1–2
3 2–3 3–6 Moderate (75–85%) 3–5 2–3
4 2–5 2–6 Moderate (75–85%) 2–5 2–3
5 2–5 1–6 Mod. heavy (85–90%) 2–5 2–5
6 FIT rule applied
RM 5repetition maximum.
Table 8
The FIT rule
Category Week 1 parameter Week 2 parameter Citation
Frequency 3 sessions/wk maximum 4 sessions/wk maximum McMaster et al., (95)
IRV 11–30 units 11–30 units McMaster et al., (95)
Time rest interval 1:4 W:R minimum *1:3 W:R minimum Casa et al., (25)
*W:R ratio after 2 weeks should be a minimum of 1:2 for the remainder of the preseason (21).
IRV 5intensity relative volume.
CSCCa and NSCA Joint Consensus Guidelines
VOLUME 41 | NUMBER 3 | JUNE 2019
16
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
can accommodate higher training vol-
umes and intensities (86,100,114).
TESTING FOR RETURN TO
TRAINING
It is paramount that strength and con-
ditioning coaches establish new base-
line testing values and compare them
with established norms or previous
baseline values. Szczepanik et al.
(133) address the need of identifying
these student-athletes that are high risk
for ER and would require screening by
medical staff during initial entry into
a collegiate sports program. It is rec-
ommended that the strength and con-
ditioning coach register a standard
conditioning test for athletes of a given
sport with the appropriate administra-
tor. As dictated by the 50/30/20/10
rule for athletes returning from ER,
EHI, or long-term inactivity, testing
should be performed at 50% of the reg-
istered test volume. If these student-
athletes are returning after a bout of
ER, this new test will provide informa-
tion on the amount of change (if any)
that needs to be addressed in training.
For example, if a coach normally uses
a repeated 300-yard shuttle test with
a 2-minute rest to assess the percentage
of change between the first and second
test, he or she would instead use a single
300-yard test. A poor performance on
this test compared with data on file or
normative data would require the
strength and conditioning coach to
assign longer recovery (3–5 minutes)
or lower volume (e.g., distances com-
pleted) for those athletes. Furthermore,
Satkunskiene et al. (119) suggest that
running technique may be slightly
altered after acute muscle damage, and
that consequently, coaches should note
and monitor any changes in running
technique. Anaerobic baseline tests
should be specific to each sport and
appropriate for the student-athlete re-
turning to training. It is of paramount
importance that the strength and con-
ditioning coaching staff closely moni-
tor the athletes during these tests for
signs of distress, curtailing the test if
appropriate. The nature of ER requires
that the conditioning be individualized
as the recovery period will vary with
each student-athlete and his or her
speed of adaptation (30,42).
CONCLUSION
The implementation of the new
CSCCa and NSCA guidelines to
include the documentation of testing
and training programs is essential for
the prevention of EHIs, ER, and inju-
ries related to preexisting cardiorespi-
ratory conditions or genetic factors.
Substantial evidence indicates that stu-
dent-athletes are at a significantly
greater risk when they return to train-
ing following a period of inactivity,
during the active recovery phase fol-
lowing an injury, or when there is
a change in coaching staff. The
strength and conditioning staff should
carefully plan, implement, and evaluate
testing protocols and training pro-
grams and provide documentation to
the designated athletic administrator
or university compliance officer. The
documentation and submission of
these assessments and training pro-
grams is the minimum requirement,
and more precise monitoring and doc-
umentation of athletes’ fitness level,
health status, hydration level, and use
of medications and dietary supple-
ments is strongly recommended.
Strength and conditioning coaches
may elect to be more conservative in
their exercise prescription based on
individual athletes’ needs or environ-
mental conditions. If there is an inci-
dent of ER, EHI, or a cardiovascular-
related event, the NCAA can begin the
investigation by consulting the docu-
mentation provided to the compliance
officer and by interviewing the student-
athletes involved. As a profession,
strength and conditioning coaches
stand at a crossroads and need to be
proactive in effecting change in the
training of all student-athletes.
Strength and conditioning coaches
must continue to develop profession-
ally with the intent of decreasing neg-
ative outcomes of student-athlete
training. The intent of these guidelines
is to provide clear parameters to
decrease the risk of issues such as
ER, EHIs, and cardiovascular-related
incidents through guidelines for
coaches in the first 2–4 weeks of man-
datory strength and conditioning train-
ing following periods of inactivity. The
50/30/20/10 rules for conditioning
activities and the FIT rule for weight
training will help strength and condi-
tioning coaches evaluate their pro-
grams and administer them in a safe
and effective manner.
SUMMARY
Based on the information presented in
these consensus guidelines, the Joint
Committee representing the CSCCa
and the NSCA provides the following
collective recommendations:
It is critical for the strength and con-
ditioning coach to have access to
preparticipation medical evaluations
(PME). Look for “red flags” on
Table 10
Plyometric training progression for return to training after exertional
rhabdomyolysis
Week Session volume
(foot contacts)
Intensity Rest time (min) Frequency (d)
1 70 Low 5 1–2
2 80–100 Low 3–5 1–2
3 80 Moderate 3–5 2–3
4 80–100 Moderate 2–5 2–3
5 80 High 2–5 2–5
6 FIT rule applied
Intensity is classified as low, moderate, or high based on vertical displacement, leg support,
velocity of movement, etc., as described by Potach and Chu (112).
Strength and Conditioning Journal | www.nsca-scj.com 17
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
pre-existing conditions (i.e., sickle
cell trait), that would put specific
athletes at risk. It is also important
for the strength and conditioning
coach to be aware of acute illnesses,
medications (both prescriptions and
over the counter drugs), and nutri-
tional supplements athletes may be
taking, (including preworkout drinks),
and side effects of those supplements
during exercise.
It is critical for the head strength and
conditioning coach to have a written
emergency action plan (EAP). Every
member of his or her staff should be
aware of the plan and know his or
her role in performing the plan in an
emergency situation. It is recom-
mended that an in-service practice
run of the procedure be performed
annually, at minimum.
All strength and conditioning
coaches should have proper educa-
tion, experience, and an NSCA-/
CSCCa-approved certification. It is
also recommended to partner and
communicate with recognized pro-
fessional organizations to review
and implement best practices to
ensure the safety of all student-
athletes. This includes working
closely with sport coaches, sports
medicine personnel, and administra-
tive staffs.
All strength and conditioning
coaches must know the early signs
and symptoms of exertional injuries
outlined in this article. This includes
exertional heat illness (EHI), exer-
tional rhabdomyolysis (ER), and
other cardiac-related issues that can
occur during training. All strength
and conditioning coaches must
monitor environmental conditions
and adjust the training volume and
intensity during extreme levels of
heat and humidity.
All strength and conditioning
coaches should provide oversight
regarding related areas that are nor-
mally handled by sports medicine
personnel. This includes monitoring
the hydration status of athletes by
daily weigh-in/weigh-out routines
and making sure ice bath and cold-
water immersion tubs are always
accessible. In addition, athletes
should be allowed to acclimatize to
extreme environmental conditions
through progressive conditioning.
The head strength and conditioning
coach should record a written con-
ditioning program that is considered
the upper limit for conditioning vol-
ume. This will be used, depending on
the status of the athlete, to determine
the maximum allowable limits using
the 50/30/20/10 rules in the first 2–
4 weeks of training after periods of
inactivity, as outlined in these guide-
lines. In addition to the 50/30/20/10
rules for returning and new athletes,
programs should adhere to the FIT
rule for resistance training.
Student-athletes who are new to the
training program (freshmen and
transfers) or returning from injuries
should be tested to determine their
current level of fitness. The test will
be determined by the head strength
and conditioning coach, but the stan-
dard tests that are used in the pro-
gram should be registered with the
appropriate athletics administrator.
It is recommended that the strength
and conditioning coach use 50% of
the volume of these standard tests
for athletes who are new to the train-
ing program or returning from injury.
Once an appropriate conditioning
program is determined for new ath-
letes, the volume should not be
increased by more than the recom-
mended amount per week. For ath-
letes returning from EHI or ER, the
progression should follow the rec-
ommendations outlined in this doc-
ument. For resistance training, the
FIT rule (sets 3reps 3%1RM as
a decimal 5IRV units) should be
followed. It is recommended that
this index stay between 11 and 30
IRV units, and a 1:4 or greater W:R
be applied to all weight training
activity (loaded, body weight, and
plyometric) in week 1, followed in
week 2 by a 1:3 or greater W:R. A
majority of strength training activi-
ties will be afforded W:Rs that far
exceed 1:4 or 1:3, but these are
the minimum standards.
Finally, it is strongly recommended
that all workouts be preplanned, so
that a written copy is logged for each
day. Once planned, the strength and
conditioning staff and/or sports
coaches should not exceed this level
of volume and intensity. Training
should not be used as a punishment
or to test the commitment and/or
mental toughness of the athletes.
These recommendations are not
exhaustive and do not address every
type of injury that can occur in all
sports. It is the responsibility of each
coach to use good judgment in design-
ing a safe and effective training pro-
gram for his or her athletes. It is the
hope of the Joint Committee that fol-
lowing these guidelines will signifi-
cantly reduce the likelihood of
preventable deaths and debilitating in-
juries from strength and conditioning
activities.
Conflicts of Interest and Source of Funding:
The authors report no conflicts of interest
and no source of funding.
ACKNOWLEDGMENTS
The authors, CSCCa, and NSCA
would like to acknowledge the contri-
butions of the following individuals in
the completion of this project: Riley
Allen (University of Mississippi); Scott
Bennett (Radford University); Jennifer
Jones (Purdue University); Ken Man-
nie (Michigan State University); Scott
Sinclair (University of Georgia); and
Brent Feland (Brigham Young
University).
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... A recent review article suggested that a 10-months moderate aerobic training with three weekly sessions improves immune responses to influenza or pneumonia vaccination in older adults (Song et al., 2020). Due to the impact of COVID-19 on different body systems, several health agencies (e.g., National Strength and Conditioning Association and Collegiate Strength and Conditioning Coaches Association Joint committee) recommend a gradual and conservative return-to-sports approach, involving weeks of low-level activity following absence of symptoms (Caterisano et al., 2019;Salman et al., 2021). Therefore, COVID-19 infections may negatively affect sports performance even after full recovery. ...
... COVID-19 infection was defined as a positive result on realtime reverse-transcription polymerase chain reaction analysis of throat swab specimens, and/or radiologic assessments including chest computer tomography according to the classification of the Radiological Society of North America (RSNA) (Simpson et al., 2020;World Health Organization, 2020). COVID individuals received rehabilitation including low-dosed running protocols as they left hospital (Caterisano et al., 2019). An experienced physiotherapist from the hospital staff provided instructions on the low-dose running protocols upon hospital discharge. ...
... An experienced physiotherapist from the hospital staff provided instructions on the low-dose running protocols upon hospita