QSU 3043 – FISIOLOGI SENAM

TAJUK: KESAN LATIHAN KETINGGIAN TERHADAP PRESTASI PEMAIN BOLA

SEPAK

NAMA AHLI KUMPULAN :

NAMA NO KAD MATRIK GAMBAR

MOHD NAZRI BIN ROSDI D20181084515

MUHAMMAD AIDIB BIN ABD D20181084495

WAHAB

MUHAMMAD FIDA’UDDIN BIN D20181084456

ABDUL HALIM

MUHAMAD HAZIQ FAUZAN BIN D20181084482

MO’ID

PENSYARAH: PROFESOR MADYA MOHD SANI BIN MADON (PhD)

1
 LATAR BELAKANG

Perkembangan sains dalam sukan dan permainan pada zaman teknologi yang

berkembang luas ini banyak memberikan pengetahuan dan didapati sangat membantu para

atlet untuk mencapai tahap prestasi yang baik.Oleh hal demikian, terdapat pelbagai alternatif

untuk membantu dalam meningkatkan produktiviti dan prestasi atlet.Namun demikian,

alternatif tersebut perlulah sesuai dan tidak melanggar undang-undang dalam sukan. Ramai

atlet mempercayai bahawa peningkatan prestasi mereka dapat ditingkatkan melalui pelbagai

cara seperti bantuan fisiologi, bantuan psikologi dan bantuan lain lagi.

Oleh itu, pada masa kini latihan ketinggian telah dipercayai sebagai kaedah yang

popular digunakan oleh ramai atlet untuk tujuan meningkatkan prestasi.Jika seseorang atlet

tinggal berhampiran paras laut dan merancang untuk bersaing di ketinggian yang lebih tinggi,

penyesuaian awal dan latihan pada ketinggian akan memberikan daya saing yang tinggi.

Namun begitu, sama ada penyesuaian badan manusia dari latihan ketinggian akan

mempunyai kesan positif atau berpanjangan pada prestasi di paras laut tidak pasti. Dengan

memahami bagaimana badan manusia menyesuaikan diri dengan ketinggian akan membantu

atlet merancang jadual latihan mereka untuk prestasi puncak di mana-mana peringkat.

Atlet dari pelbagai sukan telah menggunakan latihan ketinggian sebagai persiapan

untuk pertandingan atau acara besar, dan bukan hanya apabila acara itu dilangsungkan pada

ketinggian yang tinggi.Pendakian tiba-tiba ke ketinggian yang tinggi boleh memberi impak

besar kepada prestasi atlet anda. Oleh kerana tekanan atmosfera yang rendah pada ketinggian

tinggi, tekanan separa oksigen yang anda nafas lebih rendah daripada paras laut,

mengurangkan jumlah oksigen yang tersedia untuk aktiviti fizikal. Apabila oksigen

dikurangkan ke tahap yang menjejaskan prestasi anda, anda dikatakan hypoxic. Menurut ahli

fisiologi senaman Frank B. Wyatt, PhD, pada ketinggian sekitar 5, 000 kaki, VO2 maks anda,

2
jumlah maksimum oksigen yang boleh anda gunakan semasa latihan, mula berkurangan dan

penurunan prestasi anda. VO2 max turun secara linear dengan kenaikan tambahan dalam

ketinggian melebihi 5, 000 kaki pada kadar kira-kira 3 peratus setiap 1, 000 kaki.

Hypoxia mencetuskan satu siri tindak balas metabolik yang membantu atlet

menyesuaikan diri dengan persekitaran baru, proses yang dikenali sebagai penyesuaian.

Menurut Wyatt, kadar aklimatisasi individu boleh berkisar dari dua minggu hingga beberapa

bulan. Satu penyesuaian yang signifikan kepada hipoksia adalah peningkatan sel darah merah

dan hemoglobin, protein pengangkut oksigen yang terdapat dalam sel darah merah.

Berglund., 1992, melalui buku "Perubatan Sukan," mendapati bahawa dengan latihan

tetap, hemoglobin meningkat pada kadar kira-kira 1 peratus setiap minggu. Kerana perbezaan

hemoglobin di antara paras laut dan ketinggian tinggi adalah kira-kira 12 peratus, Berglund

berspekulasi bahawa ia akan mengambil masa kira-kira 12 minggu untuk para atlet dapat

disesuaikan sepenuhnya.

3
ULASAN KAJIAN

Menurut George P. Nassis (2013) mengkaji dan menganalisis kesan altitude terhadap

prestasi bola sepak. Data yang diperolehi dalam bola sepak terhad, dan maklumat daripada

pertandingan rasmi sukan lain juga sukar diperolehi. Tujuan kajian ini dilakukan adalah untuk

mengkaji kesan “high altitude” pada prestasi bola sepak semasa Piala Dunia 2010 di Afrika

Selatan. Ia telah dihipotesiskan bahawa jarak yang dikuasai oleh seseorang pemain, dan

indeks ketahanan akan dikurang dalam altitud melebihi 580 m, dan kemahiran teknikal akan

terjejas keranan altitud mengubah ciri-ciri bola. Prestasi fizikal, jaringan gol dan kesilapan

penjaga gawang yang telah dicatat dari statistik permainan rasmi Fe'de'ration Internationale

de Football Association semasa Afrika Selatan menjadi tuan rumah Piala Dunia 2010. Di sana

pertandingan telah dimainkan di altitud paras laut (Altitud: 0m), 660, 1200-1400 m dan 1401-

1753 m. Selepas ujian data secara normal, perbezaan-perbezaan diperiksa dengan

menganalisis dengan menggunakan kaedah satu-arah varian. Hasil pemeriksaan menunjukkan

jarak yang dikuasai oleh seseorang pemain 3.1% lebih rendah semasa perlawanan dimainkan

pada 1200-1400 m dan 1401-1753 m (0.05) berbanding dengan paras laut. Indeks daripada

kemahiran teknikal, termasuk bilangan jaringan gol setiap permainan dan kesilapan yang

dibuat oleh penjaga gawang didapati tidak berbeza dengan altitud. Di sini disimpulkan

bahawa bermain bola sepak di atas 1200 m mempunyai kesan negatif terhadap ketahanan

akan tetapi tidak berdasarkan kemahiran teknikal semasa perlawanan Piala Dunia 2010. Hal

ini memperlihatkan bahawa pasukan harus mengikuti beberapa hari aklimatisasi sebelum

bermain pada ketinggian serendah 1200 m, untuk memperbaiki kesan negatif altitud pada

prestasi fizikal.

4
 Selain itu, ia juga disokong oleh Tyler Williams dan Christopher Walter (2011) yang

telah menjalankan kajian tentang Pasukan bola sepak sering bersaing di ketinggian melebihi

2,000 meter (6,562 kaki) dengan kelayakan Piala Dunia. Media, peminat dan pemain sering

mempersoalkan keadilan bermain di ketinggian tinggi, dan FIFA telah melarang pertandingan

antarabangsa melebihi 2,500 meter (8,200 kaki) pada tahun 2007. Para penyelidik bersetuju

bahawa perjalanan ke tempat pertandingan yang ketinggiannya yang lebih tinggi atau lebih

rendah boleh merosakkan prestasi atlet.Tetapi bagi pemain professional, masalah ini mungkin

terlalu kecil untuk mempengaruhi menjejaskan keputusan perlawanan. Di samping itu,

banyak pasukan cuba untuk mengehadkan kesan altitud dengan membenarkan pemain

meluangkan masa untuk menyesuaikan diri sebelum perlawanan. Untuk mengenal pasti kesan

perubahan altitud, pengkaji telah membandingkan keputusan perlawanan peringkat

antarabangsa bagi benua Amerika Selatan dengan mengkaji perlawanan pasukan yang sama

tetapi bermain di altitude yang berbeza di dalam negara yang sama. Pendekatan ini mengawal

kecekapan seperti jarak perjalanan untuk negara-negara yang mempunyai altitud yang tinggi

dan rendah.Pengkaji mendapati bahawa perjalanan ke altitud yang lebih rendah tidak

menjejaskan prestasi tetapi perjalanan ke altitud yang lebih tinggi mempunyai kesan

negatif.Khususnya, pasukan pihak lawan menunjukkan prestasi yang buruk di Quito, Ecuador

(2,800 meter), dan La Paz, Bolivia (3,600 meter).Walau bagaimanapun, pasukan pihak lawan

agak baik di Bogot, Colombia (2,550 meter). Kami membuat kesimpulan bahawa altitud

stadium tidak boleh ditetapkan di bawah 3,000 meter tanpa pembenaran lanjut kerana ia dapat

memberikan kesan negatif kepada pasukan pelawat dan kesan positif kepada tuan rumah.

Tambahan pula, Patrick E McSharry ( 2007 ) telah melakukan kajian review keatas

kajian-kajian lampau yang didapati dari pangkalan data yang meluas FIFA yang yang

berkaitan tentang 1460 jumlah permainan bola sepak di 10 negara yang merangkumi lebih

100 tahun. Dalam review ini menunjukkan kesan negatif terhadap prestasi fisiologi seperti

5
yang dinyatakan melalui keseluruhan prestasi yang kurang baik daripada pasukan altitude

yand rendah apabila bermain dengan pasukan altitud tinggi. Pasukan altitud tinggi

menjaringkan gol lebih banyak dan mempunyai bilangan gol yang bolos lebih sedikit dengan

perbezaan ketinggian yang semakin meningkat.Setiap tambahan 1000m altitud berbeza

meningkatkan perbezaan pencapaian lebih kurang separuh daripadanya.Oleh itu, altitud

memberi kelebihan yang ketara untuk pasukan altitud tinggi bermain bola sepak dalam

peringkat antarabangsa di kedua-dua altitud rendah dan tinggi. Pasukan altitud rendah tidak

dapat menyesuaikan diri dengan altitud yang tinggi maka dengan itu n prestasi fisiologi diri

mereka akan berkurangan.

Namun begitu, Sargent C et al ( 2013 ) telah melakukan kajian iaitu ujian tidur di

tempat beraltitud tinggi dengan menggunakan 10 orang pemain bola sepak Australia bawah

17 tahun bermalam kem latihan Bolivia selama 18 hari, beberapa malam berdekatan dengan

aras laut di Santa Cruz ( 430 m ) dan beberapa malam di tempat beraltitude tinggi iaitu di La

Paz ( 3600 m ). Hasil kajian mendapati bahawa keputusan rapid eye movement ( REM )

semasa tidur itu menurun sebaik sahaja berada di beraltitud tinggi dan keadaan “hypopneas”

dan “desaturations” lebih tinggi; tahap oksigen lebih rendah; dan pusat apnoeas, rangsangan

pernafasan dan pernafasan berkala berkeadaan sangat tinggi. Kesan REM berkeadaan normal

dengan semua peserta akan tetapi kesan pernafasan terjadi hanya kepada separuh dari peserta.

Oleh itu, dapat disimpulkan bahawa ketinggian 3600 akan mengurangkan jumlah Rapid Eye

Movement (REM) yang diperoleh oleh atlet elit muda, dan menyebabkan peserta mengalami

gangguan pernafasan semasa tidur. REM kembali normal selepas 2 minggu pada ketinggian,

tetapi masih tidak ada perubahan terhadap ganguan pernafasan semasa tidur bagi atlet elit

muda Australia ini. Maka dengan itu, prestasi atlet elit muda akan berkurangan atas faktor

gangguan pernafasan semasa tidur

6
 Pada tahun 2013, Christopher J. Gore dan rakan-rakannya mengukur prestasi berjalan,

pola kesihatan dan tidur pasukan bola sepak Australia bawah 17 tahun dan pasukan Bolivian

bawah 20 tahun yang merupakan pasukan 'yang paling kuat' dari La Paz semasa lima

perlawanan di Bolivia. Pasukan itu bermain dua perlawanan selama lima hari di Santa Cruz,

di ketinggian 430m, kemudian tiga perlawanan dalam 12 hari keesokan harinya di La Paz

yang mempunyai ketinggian 3,600m. Rob Aughey yang merupakan salah seorang pengkaji

berkata data perlawanan GPS, ujian pecut, sampel darah, pemeriksaan kesihatan dan data

pemantauan tidur semuanya direkodkan untuk mendapatkan gambaran yang jelas tentang apa

yang berlaku secara fizikal ketika kedua-dua kumpulan bermain, mengembara dan berehat di

ketinggian yang berbeza.

"Walaupun FIFA dan badan-badan sukan lain telah membahaskan isu-isu kesihatan dan

keadilan bermain perlawanan pada ketinggian selama bertahun-tahun, perbincangan tersebut

tidak berdasarkan banyak bukti," katanya. "Melalui projek ini, kami menyediakan bukti

penting untuk menentukan keputusan masa depan." Kata Christopher J.Gore.

Data yang dikumpulkan di Bolivia menunjukkan bergerak ke ketinggian yang tinggi

mengurangkan jarak yang diliputi oleh semua pemain semasa pertandingan dan tidak ada

penyesuaian semula badan selama 13 hari.

7
KESIMPULAN

Kesimpulannya, walaupun terdapat percangahan dapatan dalam kajian-kajian lampau

keatas kesan latihan ketinggian terhadap prestasi pemain bola sepak, maka dapatlah dikatakan
sebahagian besar mendapati bahawa latihan ketinggian ini dapat meningkatkan prestasi atlet.
Latihan ketinggian ini digunakan bagi meningkatkan kandungan oksigen dalam darah. Hal ini
demikian kerana, kaedah latihan ketinggian ini dapat meningkatkan VO2 max mereka pada
paras laut sebanyak lima peratus, yang secara langsungnya terus meningkat dalam jumlah
jisim sel darah merah. Namun demikian, terdapat juga kajian yang menyatakan kesan negatif
terhadap latihan ketinggian tinggi ini tetapi kesan negatif itu hanya berlaku seketika sahaja
dan kembali kepada sesuatu kebaikan dan memberi kesan positif kepada tubuh badan
kita.Walau bagaimanapun, kaedah ini perlu diaplikasikan kepada kebanyakan pasukan negara
yang mempunyai aras ketinggian yang rendah kerana ianya boleh meningkatkan prestasi
seseorang atlet.

Dalam latihan ketinggian tinggi ini kita perlulah menitikberatkan tentang keselamatan
dan penyesuaian badan terhadap altitud. Antara perkara penting yang perlu diberi perhatian
dalam menyesuaikan diri dengan altitud yang tinggi dan mencegah penyakit ketinggian ialah
meningkatkan jumlah kandugan air dalam badan dengan cara minum air. Ini kerana apabila
berada ketinggian yang tinggi anda boleh mengalami sakit kepala yang teruk maka anda
dinasihatkan supaya minum air yang banyak. Dengan itu ia akan menyebabkan akan berasa
lebih segar. Selain itu, tidur dan berehat yang mencukupi juga dapat menyesuaikan badan
anda dengan ketinggian yang tinggi dengan lebih cepat.

8
RUJUKAN

D.McArdle, W. (2000). Essentials of Exercise Pysiology. Baltimore,Maryland: Lippincott

William&Wilkins.

Pinilla, O. V. (2013). Physiological Effect And Protocol. Exercise And Trainning At Altitude,
3-5.

Ploszcyca, K., Langfort, J., & Czuba, M. (2018). The Effect Of Altitude Trainning On
Erythropoietic Response And Hematological Variables In Adult Athletes:A Narrative
Review. Frontier In Physiology, 2, 6-7.

Saunders, P. U., Pyne, D. B., & Gore, C. J. (2009). Endurance Trainning At Altitude. High
Altitude Medicine And Biology, 136-138.

Sargent, Charli, et al. “The Impact of Altitude on the Sleep of Young Elite Soccer Players
(ISA3600).” British Journal of Sports Medicine, BMJ Publishing Group Ltd and British
Association of Sport and Exercise Medicine, 1 Dec. 2013 ;47:i86–i92

Taylor, L., & Rollo, I. (2014). Impact Of Altitude And Heat On Football. Sport Science
Exchange, 2-4.

Vissers, H. (2014). Altitude Trainning and Its Effect On The Human Body. A Master’s Paper
Submitted in Partial Fulfillment of The Requirements for the Degree of Master of
Science in Clinical Exercise Physiology, 6-24.

William, E. (1968). Altitude And Athletic Perfomance. British Medical Journal, 434.

William, T., & Walters, C. (2011). The Effect Of Altitude On Soccer Match Outcomes. 23-45.

9
See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/225078687

Effect of altitude on football performance: Analysis of the 2010 FIFA World Cup
data

Article  in  The Journal of Strength and Conditioning Research · May 2012

DOI: 10.1519/JSC.0b013e31825d999d · Source: PubMed

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 EFFECT OF ALTITUDE ON FOOTBALL PERFORMANCE:
ANALYSIS OF THE 2010 FIFA WORLD CUP DATA
GEORGE P. NASSIS
Department of Sport Medicine and Biology of Exercise, Faculty of Physical Education and Sport Science, National and
Kapodistrian University of Athens, Athens, Greece
ABSTRACT
Nassis, GP. Effect of altitude on football performance: Analysis
of the 2010 FIFA World Cup data. J Strength Cond Res 27(3):
703–707, 2013—Laboratory studies show that altitude ascent
impairs endurance performance. Limited data exist on football,
and information from official matches is very scarce even for
other team sports. The aim of this study was to examine the
effect of altitude on football performance during the 2010
World Cup in South Africa. It was hypothesized that (a) total
distance covered, an index of endurance, would be reduced
above the altitude of 580 m, and (b) technical skills would be
affected because altitude alters ball flight characteristics. Phys-
ical performance, goals scored, and goalkeepers’ errors that
resulted in goals conceded were recorded from the official
game statistics of Fédération Internationale de Football Asso-
ciation during the South Africa 2010 World Cup. Matches
were played at sea level (altitude: 0 m), 660, 1200–1400,
and 1401–1753 m. After testing for data normality, mean dif-
ferences were checked with a one-way analysis of variance.
Results show a 3.1% lower total distance that was covered
by the teams during the matches played at 1200–1400 and
1401–1753 m (p , 0.05) compared with sea level. Indices of
technical skills, including number of goals scored per game
and errors made by the goalkeepers that resulted in goals
conceded, did not differ with altitude. It is concluded that play-
ing football above 1200 m had negative effects on endurance
but not on technical skills during World Cup 2010 matches. It
seems that teams should follow several days of acclimatization
before playing at altitude as low as 1200 m, to ameliorate the
negative effects of altitude on physical performance.
KEY WORDS soccer, endurance, technical skills, hypoxia
Address correspondence to George P. Nassis, gnassis@phed.uoa.gr.
27(3)/703–707
Journal of Strength and Conditioning Research
Ó 2013 National Strength and Conditioning Association
Copyright © National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited.
Copyright © National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited.
INTRODUCTION
E
xposure to altitude has detrimental effects on the
human body and consequently on exercise per-
formance. Namely, it has been shown that the
reduction in oxygen partial pressure in the atmo-
spheric air reduces oxygen availability to the mitochondria,
compromises adenosine triphosphate (ATP) production via
oxidative phosphorylation, and thus reduces maximal oxygen
uptake (V_ O2max) and endurance performance (3,6,9). Indeed,
a number of laboratory studies show a reduction in V_ O2max
and aerobic performance at altitude compared with sea level
(3,6). This decline in V_ O2max has been recorded at altitudes
as low as 580 m (6).
Aside from the aforementioned aerobic responses, the
reduced air density at altitude facilitates sprint performance
and alters the aerodynamics of flying objects (9). For instance,
in the Mexico City Olympic Games held at an altitude of 2,240
m in 1968, a number of world records were set in sprinting
events because of the reduced air resistance. A theoretical anal-
ysis, based on mathematical modeling, showed a reduction in
performance from the 800 m to marathon events with increase
in altitude (12). Regarding flying ball characteristics, it has been
suggested that reduced air density at altitude would affect drag
and lift forces acting on the ball, thus altering flight character-
istics (9). This, in turn, might affect player’s technical skills (9).
Most research articles have addressed individual athletes
in specific sports, and thus findings cannot always be
generalized in team sports such as football. In team sports,
only 2 articles have examined the effect of altitude on
performance. Hamlin et al. (8) tested rugby players at sea
level and 12 hours after arrival at an altitude of 1,550 m.
Players were tested for endurance (modified 20-m shuttle
run test), repeated sprint ability (6 3 70 m agility test with
a 30-second rest), single sprint, and rugby-specific fitness
test. Analysis showed a significant decline in endurance per-
formance measurements only (8).
In another study, McSharry (11) and Gore et al. (7) ana-
lyzed 1,460 football matches to assess the effect of altitude on
results. After normalizing the number of goals scored and
goals conceded for each game relative to the mean number
of goals scored and goals conceded for each team (7), they
concluded that (a) sea-level teams playing against teams that
are residents of moderate/high altitude have a low probability
VOLUME 27 | NUMBER 3 | MARCH 2013 | 703
 Altitude and Football Performance

covered in team’s ball

TABLE 1. Summary of available data for the analysis.
Number 0 660
Matches 64 23 4 16
Teams available for the analysis 128 46 8 32
Teams not included 23 7 0
Teams in the analysis 105 39 8 25
to win when playing away, and (b) teams that are residents of
moderate/high altitude showed low probability to win at sea
level. The first finding further evidences the detrimental effect
altitude can have on performance. The latter finding indicates
that altitude-induced changes in ball’s flight characteristics
might diminish neuromuscular coordination of high-altitude
resident players when competing at sea level. This, in turn,
might explain their low probability to win at sea level (9).
Hosted in South Africa, the Fédération Internationale de
Football Association (FIFA) 2010 World Cup matches were
played at altitudes ranging from 0 m (Durban) to 1,753 m
(Johannesburg). Theoretically, altitudes above 580 m would
have negatively affected endurance performance during
matches (6). In addition, technical skills could have been
altered at altitude because a reduced air density might affect
flying ball characteristics and goalkeepers’ reactions (9).
Therefore, the aim of the present study was to examine
the effect of altitude on football performance using match
analysis data from the 2010 World Cup.
METHODS
Experimental Approach to the Problem
Certain physical and technical data collected during the 2010
World Cup matches were used in this analysis. Physical
characteristics included total distance covered, distance
possession, distance cov-
ered without team’s ball
Altitude (m) possession, and top run-
ning speed. Number of
1200–1400 1401–1753 goals scored and goals
21 conceded due to goal-
42 keepers’ error were in-
7 9 cluded in the analysis as
33 indices of technical
performance.
Subjects
Outfield players were in-
cluded in the physical
analysis, and goalkeepers were only included in the technical
analysis. Players dismissed with a red card before 75 minutes
of elapsed match time were also excluded from further
analysis. Because of the nature of the study, no informed
consents were collected from the players. The study was
approved by a university-based ethics committee.
Procedures
The FIFA 2010 World Cup was staged in South Africa from
June 11 to July 11, 2010. Sixty-four games were played at
9 cities of varying altitudes. These cities and the correspond-
ing altitudes were Cape Town (0 m), Durban (0 m), Port
Elizabeth (0 m), Nelspruit (660 m), Polokwane (1,312 m),
Pretoria (1,370 m), Bloemfontein (1,400 m), Rustenburg
(1,500 m), and Johannesburg (1,753 m). Eight games were
played in Cape Town, 7 in Durban, 8 in Port Elizabeth, 4 in
Nelspruit, 4 in Polokwane, 6 in Pretoria, 6 in Bloemfontein,
6 in Rustenburg, and 15 in Johannesburg. Of the 64 matches,
48 were played in group stage and 16 in stage 2 (round of 16,
quarter finals, semifinals, third and fourth places, and finals).
One hundred twenty-eight teams were available for the
physical performance analysis (64 matches 3 2). For various
reasons (explained below and in Table 2), 23 teams were not
included in the analysis. Thus, data from 105 teams were
analyzed (Table 1). The distribution of teams included in

TABLE 2. Detailed analysis of teams not included in the analysis.

Altitude (m) 0 660 1200–1400 1401–1573

Group stage (number of teams) 4 0 3 3

Expulsion earlier than 75 min 4 0 3 1
Missing data 0 0 0 2
Stage 2 (round of 16, quarter finals, semifinals, third 3 0 4 6
and fourth places, and final number of teams)
Expulsion earlier than 75 min 1 0 0 0
Missing data 2 0 0 2
Extra time 0 0 4 4

the TM

704 Journal of Strength and Conditioning Research

Copyright © National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited.

Copyright © National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited.
 the TM

Journal of Strength and Conditioning Research | www.nsca.com

It was hypothesized that

(a) total distance covered, an
index of endurance, would be
reduced starting at an altitude
of 660 m, and (b) technical
skills would be affected because
altitude alters ball flight
characteristics.
Statistical Analyses
The normality of distribution
was checked for all variables
with the Kolmogorov-Smirnov
test. All variables were nor-
mally distributed. Differences
between match play locations
were assessed with a one-way
analysis of variance (ANOVA)
with 4 levels (corresponding to
the 4 altitude levels). Where
a significant difference was
found with ANOVA, a Fisher’s
Least Significant Difference
Figure 1. Team’s total distance covered at different altitudes in the 2010 World Cup matches (sea level, n = 39 post hoc test was employed.
teams; altitude of 660 m, n = 8 teams; 1200–1400 m, n = 25 teams; 1401–1753 m, n = 33 teams). *p , 0.05 vs.
sea level.
A p value of ,0.05 was used
as a criterion of statistical sig-
nificance. Statistical analyses
the analysis and those not included are presented in Tables 1 were completed with SPSS (version 13.0; SPSS 13.0,
and 2, respectively. Teams not included were those in which Armonk, NY, USA). Values are presented as mean 6 SD
a player was dismissed with a red card before the 75th minute in tables and mean 6 SE in figures and in text.
and those that played extra time (only in stage 2 matches).
Data were grouped according to altitude as sea level (0 m, n = RESULTS
39 teams), at 660 m (n = 8 teams), 1200–1400 m (n = 25 teams), Total distances covered during matches played above 1200 m
and 1401–1753 m (n = 33 teams). All physical and technical were significantly lower than those at sea level (106.9 6 4.3 km
characteristics were analyzed per team. Data were recorded at sea level, 105.9 6 10.5 km at 660 m, 103.5 6 5.4 km at
from the official FIFA website (http://www.fifa.com/worldcup/ 1200–1400 m, and 103.6 6 5.2 km at 1401–1753 m; p , 0.05;
statistics/players/distanceandspeed.html, during the World Figure 1). No difference was found between 660 m and at sea-
Cup, and www.fifa.com/worldcup/archive/southafrica2010/ level performance. However, distances covered both with and
statistics/index.html, after the World Cup). without ball possession, and top running speed, did not differ

TABLE 3. Total distance covered with and without ball possession, top running speed, and technical skill performance
at different altitudes during the 2010 World Cup matches.*

Distance covered
Distance covered in without ball Top running Goals scored Errors by
Altitude ball possession (km) possession (km) speed (km$h21) per game (n) goalkeeper (n)

Sea level (0 m) 42.9 6 5.5 43.4 6 7.7 27.74 6 2.12 2.4 6 2.0 0.4 6 0.6
660 m 41.6 6 9.8 43.1 6 1.1 28.26 6 1.61 2.3 6 0.9 0.3 6 0.5
1200–1400 m 40.0 6 6.3 40.1 6 6.4 27.91 6 2.41 1.7 6 1.4 0.2 6 0.4
1401–1753 m 40.0 6 6.3 41.7 6 7.2 28.40 6 2.21 2.6 6 1.4 0.2 6 0.3

*Values are mean 6 SD.

VOLUME 27 | NUMBER 3 | MARCH 2013 | 705

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 Altitude and Football Performance
between the game locations (Table 3). Also, no differences
were found in the number of goals scored and goalkeeper
errors that resulted in goals conceded between the match
locations (Table 3).
DISCUSSION
The main finding of this study was that the teams’ endurance
performance, determined by the total distance covered dur-
ing the game, was 3.1% lower in the matches played at
altitudes above 1,200 m during the 2010 World Cup com-
pared with sea-level values. However, it is noteworthy that
the maximal speed, the number of goals scored, and the
errors made by the goalkeepers that resulted in goals con-
ceded were not significantly influenced by altitude. This is
the first study to show the effect of altitude on football per-
formance using physical and technical data from official
matches.
The negative effects of hypoxia on exercise performance
have been shown in a number of laboratory studies (3,4,6,15).
Namely, in endurance athletes, V_ O2max declines approxi-
mately 0.5–1% for every 100 m altitude above sea level (15),
and this drop is observed at altitudes as low as 580 m (6,14).
In this study, the critical altitude was detected at an ascent
above 1,200 m, which is in contradiction to the laboratory
studies. In particular, the total distance covered by the players
during the matches at that altitude (1,200 m) was almost 3.1%
lower compared with that in the sea-level matches in this
study. Of course, no direct comparison of the present findings
with the aforementioned studies can be made because foot-
ball is a more complex activity than an endurance run, and it
involves repeated bouts of low to maximal exercise for
a period of at least 90 minutes.
There is a lack of information regarding the effect altitude
may have on performance in team sports. In the single
experimental study, Hamlin et al. (8) reported a 3.4% decline
in the endurance performance (modified 20-m shuttle run
test) for rugby players tested at an altitude of 1,550 m, an
almost similar result to this study.
The 3.1% drop in endurance performance with altitude in
this study could be because of a reduction in V_ O2max result-
ing in a higher relative exercise intensity at any given absolute
rate of movement. This in turn might have led to a higher
perception of effort and fatigue than at sea-level work (6).
The diminished V_ O2max was probably because of the lower
oxygen partial pressure at altitude that resulted in lower ATP
production via mitochondrial oxidative phosphorylation
(5,9). It is of note that the detrimental effect of hypoxia on
aerobic performance is greater in well-trained athletes than in
untrained individuals, and this should be taken into account
when applying these findings to other populations. The
greater V_ O2max reduction in well-trained athletes is attrib-
uted to the diminished diffusion capacity of the lung in these
athletes compared with untrained individuals (13).
Maximal running speed was not affected by altitude
during the World Cup 2010. Similar results have been
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reported by Hamlin et al. (8). In their study, sprint times in
single straight-line sprints did not differ when rugby players
were tested at 1,550 m and at sea level (8). This was
unexpected because the lower air density at altitude should
facilitate sprint performance. Indeed, a previous study has
shown an almost 1% improvement in 100 m performance
at 1,500 m of altitude (12). However, sprint distances in
football game average only 6–8 m (2), and football players
rarely achieve their maximum speed in games because they
usually do not run in a straight line. These factors may
explain the absence of sprint time difference with altitude
in the 2010 World Cup.
Previous research attributed the improvement in sprint
time experienced at altitude to the lower air density (12).
Reduced air density could also, theoretically, affect ball aero-
dynamics, flight characteristics, and consequently the play-
ers’ technical skills (9). Indeed, the 2 forces acting on a flying
ball, drag and lift, are directly proportional to air density. Air
density reduces about 3% for every 305 m increase in altitude
(9), which means a reduction of approximately 6% at 660 m,
approximately 12% at 1,200 m, and approximately 15–18%
at 1,753 m. In practical terms, this means that the ball would
project further and curve less at altitude, which might
change the ability to score a goal and for goalkeepers to
follow and anticipate the flight of the ball. However, neither
the number of goals scored nor the number of goals con-
ceded because of goalkeepers’ errors were affected by alti-
tude at the World Cup 2010 games. This could be because of
the teams’ acclimatization in altitude, although no such data
are available in this study and supporting evidence is lacking
in the literature.
Indeed, pretournament altitude acclimatization could have
impacted teams’ physical and technical performance, which
might have affected these results. To the author’s knowledge,
the effect of acclimatization period on team sports perfor-
mance is unclear. Although the recommendation is clear for
playing games at elevations above 2,000 m, it is not the same
for lower altitudes (7). Hamlin et al. (8) showed that pre-
acclimatization via intermittent hypoxic exposure (breathing
hypoxic gas for 60 minutes per day for about 2 weeks) had
an unclear effect on endurance, single, and multiple sprints
performance at an altitude of 1,550 m (8). The recommen-
dation, based on the consensus statement on playing football
at different altitudes is that football players “would likely
benefit from several days of acclimatization in situ” when
playing at altitudes as high as 1,700 m (1,7).
A wide interindividual variability in the level of V_ O2max
reduction at a certain hypoxia and hence altitude has been
reported (10), and this should also be taken into account
when applying these data to other teams or players. For
instance, Hamlin et al. (8) reported a variation in endurance
performance decline from 20.2 to 26.5% within 12 hours of
testing at 1,550 m. Genetic variation might also explain
individual differences in performance at altitude (10). Finally,
one must remember that performance in football is

multifactorial requiring a mixture of physical, technical, and
tactical aspects. A number of these factors were not evalu-
ated in this study, and this should be taken into account
when interpreting these results.
PRACTICAL APPLICATIONS
Playing football at altitude above 1,200 m might decrease
endurance performance but has no effect on certain techni-
cal aspects. To avoid physical performance decline that
might decide match results when teams of almost similar
technical and tactical quality compete, coaches should plan
several days of acclimatization before playing official
matches at altitudes. Thus, teams should not fly to altitudes
of 1,500–1,700 m just 1–2 days before a football match, as is
common practice, but should acclimatize for several days as
suggested by the literature.
ACKNOWLEDGMENTS
No funding was available. No competing interest to declare.
The results of this study do not constitute endorsement of
the product by the authors or the National Strength and
Conditioning Association. The author wishes to thank
Dr. Michail Keramidas for his valuable comments on the
revised manuscript.
REFERENCES
1. Bartsch, P, Saltin, B, and Dvorak, J. Consensus statement on playing
football at different altitude. Scand J Med Sci Sports 18: 96–99, 2008.
2. Bradley, PS, Sheldon, W, Wooster, B, Olsen, P, Boanas, P, and
Krustrup, P. High-intensity running in English FA Premier League
soccer matches. J Sports Sci 27: 159–168, 2009.
3. Chapman, RF, Stager, JM, Tanner, DA, Stray-Gundersen, J, and
Levine, BD. Impairment of 3000m run time at altitude is influenced
by arterial oxyhemoglobin saturation. Med Sci Sports Exerc 43:
1649–1656, 2011.
Copyright © National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited.
Copyright © National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited.
View publication stats
the TM
Journal of Strength and Conditioning Research | www.nsca.com
4. Clark, SA, Bourdon, PC, Schmidt, W, Singh, B, Cable, G, Onus, KJ,
Woolford, SM, Stanef, T, Gore, CJ, and Aughey, RJ. The effect of
acute simulated moderate altitude on power, performance
and pacing strategies in well-trained cyclists. Eur J Appl Physiol 102:
45–55, 2007.
5. Fulco, CS, Rock, PB, and Cymerman, A. Maximal and submaximal
exercise performance at altitude. Aviat Space Environ Med 69: 793–
801, 1998.
6. Gore, CJ, Little, SC, Hahn, AG, Scroop, GC, Norton, KI,
Bourdon, PC, Woolford, SM, Buckley, JD, Stanef, T, Campbell, DP,
Watson, DB, and Emonson, DL. Reduced performance of male and
female athletes at 580m altitude. Eur J Appl Physiol Occup Physiol 75:
136–143, 1997.
7. Gore, CJ, McSharry, PE, Hewitt, AJ, and Sauders, PU. Preparation
for football competition at moderate to high altitude. Scand J Med
Sci Sports 18: 85–95, 2008.
8. Hamlin, MJ, Hinckson, EA, Wood, MR, and Hopkins, WG.
Simulated rugby performance at 1550-m altitude following
adaptation to intermittent normobaric hypoxia. J Sci Med Sport 11:
593–599, 2008.
9. Levine, BD, Stray-Gundersen, J, and Mehta, RD. Effect of altitude
on football performance. Scand J Med Sci Sports 18: 76–84, 2008.
10. Martin, DS, Levett, DZ, Grocott, MP, and Montgomery, HE.
Variation in human performance in the hypoxic mountain
environment. Exp Physiol 95: 463–470, 2010.
11. McSharry, PE. Altitude and athletic performance: statistical analysis
using football results. BMJ 335: 1278–1281, 2007.
12. Perronet, F, Thibault, G, and Cousineau, DA. Theoretical analysis
of the effect of altitude on running performance. J Appl Physiol 70:
339–404, 1991.
13. Powers, SK, Dodd, S, Lawler, J, Landry, G, Kirtley, M, McKnight, T,
and Grinton, S. Incidence of exercise induced hypoxemia in elite
endurance athletes at sea level. Eur J Appl Physiol Occup Physiol 58:
298–302, 1998.
14. Terrados, N, Melichna, J, Sylven, C, Jansson, E, and Kaijser, L.
Effects of training at simulated altitude on performance and muscle
metabolic capacity in competitive road cyclists. Eur J Appl Physiol
Occup Physiol 57: 203–209, 1988.
15. Wehrlin, JP and Hallen, J. Linear decrease in VO2max and
performance with increasing altitude in endurance athletes. Eur
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VOLUME 27 | NUMBER 3 | MARCH 2013 | 707
 The Effects of Altitude on Soccer Match Outcomes∗
Tyler Williams and Christopher Walters
Massachusetts Institute of Technology

August 11, 2011

Abstract

Soccer teams regularly compete at altitudes above 2,000 meters (6,562 feet) with World Cup
qualification or other honors on the line. Media, fans, and players often question the fairness
of playing at high altitudes, and FIFA temporarily banned international matches above 2,500
meters (8,200 feet) in 2007. Researchers agree that traveling to higher or lower altitude can
harm athletic performance, but the effects on professional athletes may be too small to influence
match outcomes. Additionally, many teams try to limit altitude effects by allowing players extra
time to acclimatize before a match. To identify the causal impact of altitude change, we compare
South American international match outcomes between the same teams but played at different
altitudes within the same country. This approach controls for influences such as differences in
travel distance for high and low altitude countries. We find that traveling to lower altitude does
not affect performance but traveling to higher altitude has negative effects. In particular, away
teams perform poorly in Quito, Ecuador (2,800 meters), and La Paz, Bolivia (3,600 meters).
However, away teams do relatively well in Bogot, Colombia (2,550 meters). We conclude that
stadium altitudes should not be restricted under 3,000 meters without further justification.

∗
We thank Griffin Williams for supreme assistance with data collection and organization.

1
1 Introduction
In 2007, the Fédération Internationale de Football Association (FIFA) announced a ban on
international soccer matches above 2,500 meters (8,200 feet) unless the away team had adequate
time to acclimatize. This limit prohibited Bolivia, Colombia, and Ecuador from hosting some
matches in their capital cities. The South American soccer federation CONMEBOL and most of
its member countries quickly fought back; 47 year old former star Diego Maradona even played
in an exhibition against a side headed by Bolivian President Evo Morales at 3,600 meters in La
Paz to prove that high altitudes could be overcome. Under heavy pressure, FIFA suspended the
ban in May, 2008.
During this period, FIFA held a conference to discuss the impacts of altitude on soccer team
performance. The conference participants agreed that altitude change impacts the behavior
of a kicked ball and has negative effects on physical performance (Bärstch et al., 2008). The
primary negative effects of traveling up are aerobic, due to lower oxygen levels at high altitude,
but acute mountain sickness can cause devastating effects, even at 4,000 meters or lower. To
achieve peak physical capacity, most participants recommended that soccer players spend one to
two weeks acclimatizing before matches above 2,000 meters and at least two weeks acclimatizing
before matches above 3,000 meters (Bärstch et al., 2008). Scientific studies also suggest that
traveling to lower altitude can harm performance (Gore et al., 2008). Despite this consensus,
negative physiological effects could be small for professional athletes within reasonable altitude
ranges. Acclimatization procedures such as those recommended by the FIFA conference can also
mitigate negative effects of traveling up.
FIFA has primarily been interested in whether high altitude matches are fair; to inform this
debate, we investigate whether altitude change has any measurable impact on team performance.
We analyze match outcomes from more than 100 years of international soccer in South America,
where matches are played at altitudes ranging from sea level to over 4,000 meters. Using similar
data, Gore et al. (2008) find that teams traveling either up or down win less often than teams
that do not change altitude. These results imply fairness concerns with playing at any altitude
- concerns that perhaps balance out. However, the estimates may be biased since there are no
controls for characteristics of the away teams. In fact, another study that controls for team
characteristics and environmental factors using 10 years of recent South American data finds
no effect of altitude change on away team performance (Chumacero, 2009). Using a longer time
series, we compare matches between the same home and away teams but played at different
altitudes within the host country. This approach holds all team-specific factors constant while
allowing altitude to vary; any remaining disparities in match outcomes should be attributable
to altitude differences.
We find that traveling down has no impact on match outcomes, but traveling up has a
negative, linear effect on away team performance on average. We explore these results further by
comparing matches between the same teams played at low and high altitude in Bolivia, Colombia,
and Ecuador, country by country. FIFA’s initial upper altitude limit was just below Colombia

2
and Ecuador’s main stadium altitudes, so these comparisons are policy relevant. Teams play
worse in Ecuador when they must travel up to Quito (2,800 meters), but they actually play better
when traveling up to Bogotá (2,550 meters) to play Colombia. Visiting teams’ effectiveness at
altitude against Colombia suggests that FIFA does not need to cap altitude in the 2,500 to
3,000 meter range. Teams struggle mightily when traveling up to 3,600 meters in La Paz,
Bolivia (rather than playing at 400 meters in Santa Cruz), but we refrain from making policy
recommendations at this altitude level since our analysis relies on a single country.

2 Data and Results

The match data for this study come from the Rec.Sport.Soccer Statistics Foundation archive
(Appendix A lists copyrights and source links). This archive has score and match location data
for all international matches played by the top ten South American countries from 1902 to 2009:
Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Paraguay, Perú, Uruguay, and Venezuela.
We exclude neutral site matches. We obtained city latitudes and longitudes in order to link the
match data to precise GPS altitude data. If a geographically large city had multiple altitudes in
the database, we took the average altitude. To calculate altitude differences for the away team,
we compare the away team’s capital city altitude to the match altitude, except in the case of
Brazil. For Brazil, we use Rio de Janeiro’s altitude instead of Brasilia, since Brazil plays most
matches in Rio de Janeiro.
Using FIFA data, Gore et al. (2008) estimated the following ordinary least squares regression
model:

Wi = α + γ 0 Hi + β1 Ii + β2 Ii2 + εi , (1)

where Wi is a dummy for a home win, Hi is a vector of dummies for the home team, and Ii is
the increase in altitude for the away team (negative if the team traveled down). The authors
approximate the match altitude with each country’s main stadium altitude. This regression
yields a positive and statistically significant coefficient on the square of the altitude increase.
The coefficients imply that traveling up 2,000 meters has little impact on match outcomes, but
an away team increase of 4,000 meters increases home team winning percentage by about 8
percentage points. The authors also infer that an away team decrease of 4,000 meters increases
home team winning percentage by about 27 percentage points.
Table 1 replicates these results for the 1,551 matches in our data, using the exact altitude for
every match. As in the previous study, we estimate that the square of the away team’s altitude
increase has a statistically significant positive effect on win probability (column 1). We compute
effects of altitude change on home goals, away goals, and the score differential in columns 2
through 4, with similar results. The estimates confirm that our data do not differ substantially
from the FIFA data, but this regression is likely biased due to differences between away teams
that travel up or down. For example, this statistical approach attributes differences in Bolivia

3
and Argentina’s performances in Brazil entirely to altitude change, even though Bolivia and
other high altitude countries have performed worse in all settings historically. Any away team
characteristics (such as team quality, travel distance, and financial resources) that are correlated
with altitude change and with match outcomes will bias the estimated altitude effects.
In table 2, we include a full set of interactions between home and away team dummy variables.
Effects from this specification tell us whether altitude changes influence matches between the
same home and away team. For example, this approach compares match outcomes between
Ecuador and Brazil played in Quito, Ecuador (2,800 meters), versus Guayaquil, Ecuador (sea
level). In this comparison, the home and away teams are the same, and Brazil faces similar travel
requirements, so we can attribute any disparity in match outcomes to the altitude difference. We
drop 277 matches from the data because some pairs of teams always play at the same altitude.
The estimates in panel A of table 2 provide evidence that traveling up or down has little
influence on match outcomes. The quadratic effects are of the same sign as in table 1 but they
are much smaller and estimated less precisely. The only marginally significant result is the
effect of the squared altitude increase on goal differential (column 4). The positive sign on this
coefficient implies that teams traveling up or down lose by more goals than teams that do not
change altitude, but the effect is not large enough to generate a significant effect on winning or
losing (column 1).
These results suggest that altitude changes are not very important, but there may still be
specification error. A quadratic form artificially forces the effects of traveling up or down to be
on the same curve. In panel B of table 2, we estimate separate linear effects of traveling up or
down as follows:

Wi = α + γ 0 (Hi ∗ Ai ) + β1 (Ii ∗ 1[Ii > 0]) + β2 (−Ii ∗ 1[Ii < 0]) + εi . (2)

Here, β1 is the effect of traveling up and β2 is the effect of traveling down, which is estimated
independently. The Hi ∗ Ai term represents the interactions between home and away team
dummies.
Column 1 of panel B in table 2 shows that home team winning percentage increases by over 5
percentage points for each 1,000 meters that the away team must climb (statistically significant
at the one percent level). Effects on goals scored in columns 2 through 4 also suggest large
negative effects of traveling up, although they are not estimated precisely. Traveling down has
no statistically significant impact on match outcomes.
These results provide evidence of an altitude advantage. However, curvature or discontinu-
ities could still bias the two-sided linear specification. Climbing 1,000 meters is probably not
enough to generate a 5 percent increase in home winning percentage, while climbing 4,000 meters
might change winning percentage by even more than 20 percent. Estimating separate quadratic
functions for traveling up and down would increase flexibility further, but within-country altitude
does not vary enough to fit such functions precisely. Instead, we perform simple, non-parametric

4
“high versus low” comparisons on matches played in Bolivia, Colombia, and Ecuador.1
In all three countries, a substantial number of matches are played at high altitude and near
sea level. Figure 1 shows that, in Bolivia and Ecuador, teams that climbed at least 2,000 meters
for a match fared much worse than teams that did not. Both countries won over 50 percent of
their home matches against climbing teams (mostly in La Paz and Quito) but only around 30
percent of their matches against teams that did not climb (mostly in Santa Cruz and Guayaquil).
However, Colombia shows the opposite pattern, winning just 45 percent against climbing teams
(mostly in Bogot) but 57 percent against teams that did not climb (mostly in Barranquilla).
In Table 3, we show that these simple comparisons hold when controlling for home and
away team characteristics. We run a separate regression for each country, capturing the altitude
effects with a dummy equal to one if the away team climbed over 2,000 meters. Panel A includes
away team dummies to control for biases due to team quality (as in Table 2).2 Panel B adds
controls for each team’s yearly winning percentage in low altitude games to capture changes in
team quality over time.3
The two panels in Table 3 show nearly identical results. Forcing the away team to climb
boosts Bolivia’s winning percentage by 45 percentage points and Ecuador’s winning percentage
by 25 to 30 percentage points (both effects significant at the one percent level). Colombia’s
winning percentage drops by about 20 percentage points when teams must climb to Bogotá.
The effect for Colombia is not statistically significant but, at minimum, it implies that Colombia
does not gain an advantage from playing at high altitude.

3 Conclusions
Using a two-sided linear regression model on over 100 years of match data, we find that home
teams have a distinct advantage in South American international soccer when away teams travel
up for a match. In contrast with previous work with similar data (Gore et al., 2008), we control
for away team quality and find that traveling down has no impact on match outcomes. Country-
specific analysis shows that away teams have had success playing Colombia at an altitude of
2,550 meters, even when controlling for team quality. However, Ecuador’s winning percentage
increases by 25 to 30 percentage points when they play just 250 meters farther up in Quito.
The altitude advantage is even larger at 3,600 meters in Bolivia (45 percentage points). Future
work should consider whether the 250 meters between Colombia and Ecuador or other aspects
of home field advantage can explain these differences. We rule out strategic scheduling as an
explanation by controlling for yearly low-altitude winning percentage.
Away teams’ success at over 2,500 meters in Colombia should give FIFA pause when con-
sidering an altitude restriction under 3,000 meters. Although Bolivia appears to have a strong
1
We focus on traveling up since FIFA has primarily looked at whether altitude increases hurt performance.
2
There is no need to interact the away team dummies here, since there is only one home team in each regression.
3
In particular, we worried that Bolivia, Colombia, and Ecuador schedule games at high altitude when the away
team is having a strong year (or they themselves are having a weak year) to increase their chances of winning.
Without yearly team quality controls, such strategic scheduling could bias altitude effects downwards.

5
advantage at 3,600 meters, we advise looking at these results in detail and collecting more data
before using them to justify a limit over 3,000 meters. Our statistical findings do not take ethical
arguments into consideration, either. High altitude is part of many countries’ culture, and other
environmental factors remain largely unregulated (e.g., temperature, humidity, and air quality).
Altitude does seem to generate an advantage, but any restriction must take all of these factors
into account.

References
Bärtsch, Peter, Bengt Saltin, and Jiri Dvorak. 2008. “Consensus Statement on Playing
Football at Different Altitude,f” Scandinavian Journal of Medicine & Science in Sports 18(Sup-
plement 1): 96-99.
Gore, C. J., P. E. McSharry, A. J. Hewitt, and P. U. Saunders. 2008. “Preparation for
Football Competition at Moderate to High Altitude,” Scandinavian Journal of Medicine &
Science in Sports 18(Supplement 1): 85-95.
Chumacero, Rómulo A. 2009. “Altitude or Hot Air.” Journal of Sports Economics 10(6):
619-638.

A Data Sources and Copyrights

South American international match data:

http://www.rsssf.com/intland.html

Argentina: Héctor
c Daro Pelayes and RSSSF 1998/2009
Bolivia: Marcelo
c Leme de Arruda, RSSSF and RSSSF Brazil 2002/2009
Chile: Frank
c Ballesteros, Luis Antonio Reyes and RSSSF 2000/2005
Colombia: Frank
c Ballesteros and RSSSF 1999/2009
Ecuador: Fernando
c Espinoza Añazco and RSSSF 2003/2009
Paraguay: Frank
c Ballesteros, Eli Schmerler and RSSSF 2000/2006
Peru: José
c Luis Pierrend and RSSSF 1998/2009
Uruguay: Martı́n
c Tabeira and RSSSF 2002/2009
Venezuela: Frank
c Ballesteros, José Luı́s Pierrend, Eli Schmerler and RSSSF 1998/2006

Latitude and longitude for cities:

http://www.kingwoodcable.com/gpswaypoints/index.htm

Altitude data:

http://www.gpsvisualizer.com/elevation

http://www.gpsvisualizer.com/elevation.html

6
 Figure
Figure 1: High Altitude Home Team Outcomes by Away Team Altitude Change

Win Percentage Average Goals

0.75 2
1.5
0.5
1
0.25
0.5
0 0
Bolivia Colombia Ecuador Bolivia Colombia Ecuador

Average Opponent Goals Average Goal Differential

2 1
1.5 0.75
1 0.5
0.5 0.25

0 0
Bolivia Colombia Ecuador -0.25 Bolivia Colombia Ecuador

>2km advantage <2km advantage

Page 1

7
 Table 1: Effects of Away Team Altitude Increase, Home Dummies Only
Home Win Home Goals Away Goals Home – Away Goals
(1) (2) (3) (4)
Altitude increase, –0.008 –0.057 0.037* –0.094**
away team (km) (0.007) (0.038) (0.023) (0.045)
Altitude increase, 0.018*** 0.048*** –0.027*** 0.075***
2
away team (km) (0.002) (0.010) (0.008) (0.013)
Observations 1,551 1,551 1,551 1,551

Notes: The table presents OLS regressions of match outcomes (listed across the top row) on a quadratic in
the away team altitude increase (negative if a decrease). The away team altitude increase equals the difference
between the match altitude and the away team’s capital city altitude (except for Brazil, which plays primarily in
Rio de Janeiro). All columns include a full set of home team dummy variables. Each observation represents one
match. We cluster standard errors at the year level and separately at the matchup level.
* significant at 10%; ** significant at 5%; *** significant at 1%

8
 Table 2: Effects of Away Team Altitude Change, Home and Away Interactions
Home Win Home Goals Away Goals Home – Away Goals
(1) (2) (3) (4)

Panel A. Quadratic Specification

Altitude increase, 0.008 0.036 –0.011 0.048

away team (km) (0.007) (0.073) (0.054) (0.104)
Altitude increase, 0.015 0.022 –0.022 0.044*
2
away team (km) (0.010) (0.018) (0.016) (0.027)

Panel B. Two-Sided Linear Specification

Altitude decrease, 0.039 0.060 -0.073 0.134

away team (km) (0.081) (0.143) 0.079 (0.197)
Altitude increase 0.055** 0.112* –0.083 0.194*
away team (km) (0.021) (0.061) (0.076) (0.107)

Observations 1,274 1,274 1,274 1,274

Notes: The table presents OLS regressions of match outcomes (listed across the top row) on a quadratic in the
away team altitude increase (negative if a decrease) in panel A and separate linear terms for the away team
altitude increase or decrease in panel B. The away team altitude increase equals the difference between the match
altitude and the away team’s capital city altitude (except for Brazil, which plays primarily in Rio de Janeiro).
All columns include full interactions of home team and away team dummy variables. Each observation represents
one match. We cluster standard errors at the year level and separately at the matchup level. We exclude matches
in which the two teams only played at one altitude within a country (the altitude difference is perfectly collinear
with the home and away interaction in that case).
* significant at 10%; ** significant at 5%; *** significant at 1%

9
 Table 3: Effects of Away Team Altitude Increase, Home Dummies Only
Bolivia Win Colombia Win Ecuador Win
(1) (2) (3)

Panel A. Away Team Dummy Controls

Away team climbed 0.453*** –0.204 0.293***

over 2 km (dummy) (0.090) (0.131) (0.101)

Panel B. Away Team Dummy and Team Quality Controls

Away team climbed, 0.450*** –0.211 0.240***

over 2 km (dummy) (0.092) (0.135) (0.121)

Observations 109 108 104

Notes: The table presents OLS regressions of home team wins on a dummy variable equal to one if the away team
climbed over 2,000 meters in altitude. The away team altitude increase equals the difference between the match
altitude and the away team’s capital city altitude (except for Brazil, which plays primarily in Rio de Janeiro).
Each column is restricted to games hosted by the country listed in the top row. Regressions in panel A include a
full set of away team dummy variables. Regressions in panel B also control for the home and away teams’ winning
percentage when playing in low altitude countries. Each observation represents one match. We cluster standard
errors at the year level.
* significant at 10%; ** significant at 5%; *** significant at 1%

10
 sport
Systems Analysis, Modelling, and
Prediction Group, Department of
Engineering Science, University of
Oxford, Oxford OX1 3PJ
patrick@mcsharry.net
BMJ 2007;335:1278-81
doi:10.1136/bmj.39393.45156.ad
See extra table on bmj.com
1278 BMJ | 22-29 December 2007 | Volume 335
Altitude and athletic performance:
statistical analysis using football results
Patrick E McSharry
Abstract
Objective To assess the effect of altitude on match results
and physiological performance of a large and diverse
population of professional athletes.
Design Statistical analysis of international football (soccer)
scores and results.
Data resources FIFA extensive database of 1460 football
matches in 10 countries spanning over 100 years.
Results Altitude had a significant (P<0.001) negative
impact on physiological performance as revealed through
the overall underperformance of low altitude teams when
playing against high altitude teams in South America. High
altitude teams score more and concede fewer goals with
increasing altitude difference. Each additional 1000 m of
altitude difference increases the goal difference by about
half of a goal. The probability of the home team winning for
two teams from the same altitude is 0.537, whereas this
rises to 0.825 for a home team with an altitude difference
of 3695 m (such as Bolivia v Brazil) and falls to 0.213 when
the altitude difference is –3695 m (such as Brazil v Bolivia).
Conclusions Altitude provides a significant advantage for
high altitude teams when playing international football
games at both low and high altitudes. Lowland teams
are unable to acclimatise to high altitude, reducing
physiological performance. As physiological performance
does not protect against the effect of altitude, better
predictors of individual susceptibility to altitude illness
would facilitate team selection.
Location and altitude
of national stadiums,
South America
CHILE
Santiago
520 m
PA RAG UAY
Asunción
ARGENTINA U R U G U A Y 60 m
Buenos Aires Montevideo BRAZIL
30 m 30 m Rio
5m
Introduction
In May 2007, football’s governing body, the Federa-
tion of International Football Associations (FIFA),
banned international matches from being played at
more than 2500 m above sea level. International foot-
ball games in South America often take place in high
altitude cities—Bogotá, Colombia (2600 m); Quito,
Ecuador (2800 m); and La Paz, Bolivia (3600 m) (see
table on bmj.com)—presenting a serious challenge to
players’ acclimatisation mechanisms, particularly for
teams playing away games at higher altitudes,1 with
the drop in air pressure making it difficult for the body
to obtain sufficient oxygen.2 At high altitude hypoxia,
cold, and dehydration can lead to breathlessness,
headaches, nausea, dizziness, and fatigue, and possi-
bly altitude illness including syndromes such as acute
mountain sickness, high altitude pulmonary oedema,
and cerebral oedema.3-8 Activities such as football can
exacerbate symptoms,9 10 preventing players from per-
forming at full capacity.11
Ability to consume oxygen, which is reduced by
acute exposure to high altitude, reflects players’ phys-
iological performance and correlates with football
performance at a national level.12 13 The Sport Medi-
cine Commission of FIFA recommends that football
matches above 3000 m should be played only after
an acclimatisation period of 10 days because of the
effects of acute exposure to altitude on performance.1
BOLIVIA
La Paz ECUADOR
3700 m Quito COLOMBIA
2800 m Bogotá
2600 m VENEZUELA
Caracas
1000 m
PERU
Lima
90 m
 Section Online First? Tech. Ed. Fig width
R No GC 72
sport

80 This high level of skill in the lowland teams serves to

Percentage of wins
Home games
disguise the influence of altitude on football perform-
Away games
60 ance in South America.
In order to investigate the dependence of perform-
40
ance on altitude, I defined four variables: (i) the prob-
ability of a win, (ii) the number of goals scored, (iii) the
number of goals conceded, and (iv) the altitude differ-
20
ence between the home venue of a specific team and
that of the opposition. The altitude difference variable,
0 ∆h, is zero when both home and away teams are from
a

ia

ne y
Co ile
il

Ur u
Pa or

ay
Ec a

a
a
the same altitude, is positive when the home team is
tin

az

r
bi

el
liv

Pe

u
gu
Ch

zu
m

ua
Br

ug
en

Bo

ra
lo
g

at high altitude and the away team has travelled up to

Ar

Ve
National team altitude, and is negative when the away team has trav-
Fig 1 | Percentage of wins at home and away for each country in
South America PROOF
elled down from altitude toward sea level. I considered
three models resulting from different combinations of
Author name
the above Filenamein order to quantify
explanatory variables
Awareness of the most efficient means of acclima- McSharry
the relative contributions ofmcsp457549.f2
the altitude and that of the
tising to altitude has important implications for all difference
Section
in performance between
Online First? Tech. Ed.
individual
Fig width
coun-
professional athletes. tries. These models were intercept and ∆h (model A);
Although it is recognised that teams acclimatised
R No GC 72
dummy variables for each country (model B); and ∆h
to high altitude benefit from favourable physiologi- and dummy variables for each country (model C).
cal conditions, the direct link with football perform-
ance at an international level has not been shown or
quantified before. I investigated the effect of altitude 1

Probability of a win
on a large and diverse population of professional
athletes. International football scores and results
0.75
offer a direct measure of the performance of different
teams at multiple altitudes, which can be linked to
their ability to acclimatise. The primary hypothesis 0.50

tested was whether and by how much altitude affects

international football performance. By using a data- 0.25
base covering a century of matches, I quantified the
dependence of football results and scores on altitude 0
and assessed how altitude can be a disadvantage or
advantage for professional athletes. 4
No of goals scored

Methods 3
By the analysis of scores of international football
games played in South America between 1900 and
2
2004, I directly assessed the influence of altitude on
football. Only home and away games were included;
1
I omitted all matches played in neutral venues. This
dataset contained football scores for 10 national
teams with a total of 1460 games. The well recog- 0
nised advantage of playing at home as opposed to
3
No of goals conceded

away is reported in detail elsewhere.14

Many factors influence the outcome of football
games—including technique, strategy, management, and
2
the players’ physiological and psychological condition. I
attempted to reduce the effect of these factors by inves-
tigating the results of football matches over more than
1
a century. By analysing football results for the entire
region of South America, I reduced the influence of any
one country. I used dummy variables to code for each 0
country, to control for the differing historical perform- -4000 -2000 0 2000 4000
ances of the individual countries. The varying abilities Altitude difference (m)
of the different teams are shown by their performances
(fig 1). The lowland teams—Brazil, Argentina, and Uru- Fig 2 | Effect of altitude difference on the probability of winning
guay—are ranked first, second, and third by the percent- (top panel) and on the number of goals scored (middle panel)
age of home wins in our dataset and have won nine of and conceded (bottom panel). The shaded area indicates the
the 17 World Cups (five, two, and two respectively). 95% confidence interval.

BMJ | 22-29 December 2007 | Volume 335 1279

 sport
Probability of a win
I investigated the probability of a win using the same
explanatory variables as above and a generalised linear
model with a binomial distribution and a logit relation.
The set of explanatory variables consisted of dummy
variables for each of the 10 countries and one variable
for the altitude difference, ∆h.
Goals scored and conceded
I used generalised linear models with a Poisson distri-
bution to describe the variation in the number of goals
scored and conceded as a function of ∆h.
Results
The home advantage for South American football teams
was reflected in the significant difference (P<0.001)
between the number of goals scored and conceded,
with averages of 1.81 and 1.04 respectively. The per-
centage of home wins was 53.7%.
The table shows the parameters and diagnostics for
the probability of a win with each of the three mod-
els. Altitude difference (model A) and country code
(model B) are significant explanatory variables when
used independently. The best fit is obtained when using
both altitude difference and country code (model C).
This result confirms that the inherent differences in per-
formance between countries do not explain the altitude
effect. Altitude difference was a significant (P<0.001)
determinant of outcome for these international football
games in both models A and C.
The average effect of altitude on the probability of
winning was calculated from model C as shown in fig 2.
The probability of a home win for two teams from the
same altitude is 0.537, whereas this rises to 0.825 for
∆h=3695 m (for example, Bolivia v Brazil) and falls to
0.213 when ∆h=−3695 m (such as Brazil v Bolivia).
Table | Parameters and diagnostics for each model of the probability of a win in international
football matches between South American countries
Generalised linear models†
Variable Model A Model B
Intercept 0.15** — —
Altitude (km) 0.21*** — 0.39***
Dummy variable for each country:
  Argentina — 0.61***
  Bolivia — 1.21***
−0.02
  Brazil — 0.87***
  Chile — 0.03
  Colombia — −0.06
  Ecuador — −0.29
  Paraguay — between the two teams and the effect this has on physi-
−0.06
  Peru — −0.28
  Uruguay — 0.34*
  Venezuela — −1.10***
Deviance 1972.12 1944.89
Akaike information criteria (AIC) 1976.12 1964.89
Bayesian information criteria (BIC) 1986.69 2017.76
R2 2.20% 3.55%
Adjusted R2 2.01% 2.56%
†Model A = intercept and altitude difference. Model B = variables for each country. Model C = altitude difference and
variables for each country. Significance: *(P<0.05), **(P<0.01), and ***(P<0.001).
1280 BMJ | 22-29 December 2007 | Volume 335
What is already known on this topic
The ability to consume oxygen, which is reduced by acute
exposure to altitude, reflects athletes’ physiological
performance
The better trained teams, on average, have higher mean
consumption rates of oxygen
What this study adds
This study quantifies the effect of altitude on football
games between the national teams of South American
countries
Teams from high altitude countries have a significant
advantage when playing football at both low and high
altitudes
I also used altitude difference and country code to
construct separate models for the number of goals
scored and the number conceded. In each model,
the coefficient for ∆h was significant (P<0.001), but its
impact was greatest on the number of goals scored.
Teams score more (and concede fewer) goals with
increasing ∆h (fig 2), suggesting that altitude difference
has a significant negative impact on performance. In
the case of two teams from the same altitude the home
team will, on average, win by 0.70 goals. For each 1000
m of altitude difference, the home team gains almost
half of a goal. In the case of Bolivia, playing at home in
La Paz, this represents on average a win by 2.18 goals
and an advantage of 1.48 goals when competing against
teams from sea level (∆h=3695 m). Of this increased
home advantage, 1.00 goal is gained by increased goal
scoring and 0.48 goal is gained by fewer goals being
conceded.
Discussion
The altitude difference between home and away teams
in international football games in South America sig-
nificantly affected the outcome of games. High altitude
home teams scored more and conceded fewer goals
when playing low altitude teams, and for each addi-
tional 1000 m of altitude difference the home team’s
Model C
score increased by about half a goal. In the case of
Bolivia playing against a sea level opponent such as
Brazil, the probability of a home win was effectively
0.48***
increased from 0.537 to 0.825 because of altitude. The
advantage of high altitude teams over their low altitude
opponents was greatest at high altitude, but it was also
0.68
present at low altitude.
−0.04**
0.65
The advantage when playing at high altitude is to be
0.47*
expected given the differential in oxygen consumption
−0.40***
ological response and football performance. The sur-
−0.66
prising result is that the high altitude teams also had an
0.15***
−1.33***
advantage when playing at low altitude, benefiting from
1882.25 a significant advantage over their low altitude oppo-
1904.25 nents at all locations. Although “living high and training
1962.40 high” is accepted as beneficial for athletes performing at
6.66% high altitude, its effects on performance at sea level are
5.57% less clear.15 A growing body of evidence indicates that
“living high and training low” is an effective training
technique, leading to increased numbers of red blood
 sport

cells, oxygen consumption, and running performance. Implications of results

It has also been shown to improve sea level perform-
ance in accomplished and elite runners.16 17
Strengths and weaknesses of study
The strength of the study is the novel approach of
using a large football database, containing results
of 1460 games played at multiple altitudes over
a 100 year period. This is in contrast to previous
­studies on the effects of altitude, which are based on
­population sizes of the order of 10.1 My statistical
analysis of football scores provides a direct measure
of the ­relation between physiological performance
and altitude that is not susceptible to the effects of
any one individual or team.
The weakness of the study is the difficulty in control-
ling for other factors that influence football outcome,
such as the quality of the training and manager. With
such a long record of data, however, the results are
unlikely to be affected by any single manager. I used
dummy variables for each country to control for the
differing levels of ability of the teams. There are other
effects of altitude such as air resistance which could
affect performance. For example, the ball travels dif-
ferently at high altitudes; it spins less, sails further,
and moves faster.
Low altitude teams may adopt different strategies to cope
with playing at high altitude. One approach is to arrive
at high altitude only hours before the game, whereas
another is to allow sufficient time for acclimatisation. The
latter approach is often not feasible given the busy sched-
ules of today’s international football players. Furthermore,
there is no agreed time for acclimatisation, apart from
the knowledge that the longer the duration of the activ-
ity and the higher the altitude, the more time required
for ­acclimatisation. When possible, the best approach
for avoiding altitude illness is to ascend slowly, allowing
­sufficient time for ­acclimatisation.6 Recommendations for
above 3000 m include increasing sleeping altitude by only
300-600 m each day and taking a rest day for every addi-
tional 1000 m in altitude. Drug treatment may also pro-
vide some protection against altitude ­illness. ­Ginkgo biloba
and aspirin have been shown to be more effective than
placebo, but most evidence ­supports the prophylactic
use of acetazolamide.6 18
Funding: This research was supported by the Royal Academy of
Engineering and the Engineering and Physical Sciences Research Council
(EPSRC) through the funding of a research fellowship.
All references and another table are in the version on bmj.com
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
Accepted: 16 October 2007

Champagne: the safer choice

for celebrations
A 24 year old Australian rules football player presented to the
­emergency department complaining of a sensation of a foreign body
stuck in his throat. The sensation was associated “with an inability
to breathe properly.” Earlier that day, when celebrating his team’s
victory in the premiership, he had downed the remaining beer in the
­premiership cup, inadvertently swallowing a beer bottle cap.
Physical examination, radiography, and fibreoptic examination of the
neck and throat were unremarkable. An anteroposterior chest radio-
gram showed a round metallic foreign body with scalloped edges at
the level of the aortic arch (figure). Blood ethanol level was 0.109 g/100
ml. A beer bottle cap was retrieved via endoscopy later that evening,
without complications.
Excessive alcohol consumption as a celebratory consequence of high
profile sporting victories is well known. Oesophageal obstruction from
a bottle cap, however, is rarely seen in emergency departments.1 2
In suspected cases, airways obstruction and injury should be rapidly
excluded.
A comprehensive Medline search failed to elicit an example of
oesophageal obstruction secondary to the ingestion of a champagne (or
wine) cork. Since the 18th century, champagne has been the beverage
of choice for celebrations3 and on current evidence should remain so.
Robert J Douglas registrar, Emergency Department, Royal Adelaide Hospital, Adelaide,
SA 5081, Australia
rabs01@hotmail.com
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
1 Prakash K, Rosario PG, Kim S. Esophageal obstruction from a beerbottle cap. N Engl J
Med 1989;321:121-2.
2 Rottman SJ, Lindsay KL, Kuritzkes R. Of college fads, bottle caps, and esophageal
obstruction. Ann Emerg Med 1988;17:869. Anteroposterior chest x ray film showing an impacted beer bottle cap at the
3 Montagne P. Larousse gastronomique. London: Hamlyn Group, 2001:242. level of the aortic arch

BMJ | 22-29 December 2007 | Volume 335 1281


1
Appleton Institute for
Behavioural Science, Central
Queensland University,
Adelaide, Australia
2
Department of Sports
Medicine/Sports Physiology,
University of Bayreuth,
Bayreuth, Germany
3 Methods Participants (n=10) were members of the
Institute of Sport, Exercise and
Active Living, Victoria
University, Melbourne,
Australia
4
Western Bulldogs Football
Club, Melbourne, Australia
5
ASPIRE Academy for Sports
Excellence, Doha, Qatar
6
Facultad de Medicina,
Instituto Boliviano de Biología
de Altura (IBBA), Universidad
Mayor de San Andrés, La Paz,
Bolivia
7
Department of Physiology,
Australian Institute of Sport,
Canberra, Australia
8
National Institute of Sports
Studies, University of Canberra,
Canberra, Australia
9
Exercise Physiology
Laboratory, Flinders University,
Adelaide, Australia
Correspondence to
Dr Charli Sargent, Appleton
Institute for Behavioural
Science, Central Queensland
University, PO Box 42,
Goodwood, Adelaide,
SA 5034 Australia;
charli.sargent@cqu.edu.au
Accepted 3 September 2013
Open Access
Scan to access more
free content
To cite: Sargent C,
Schmidt WF, Aughey RJ,
et al. Br J Sports Med
2013;47:i86–i92.
Sargent C, et al. Br J Sports Med 2013;47:i86–i92. doi:10.1136/bjsports-2013-092829
The impact of altitude on the sleep of young elite
soccer players (ISA3600)
Charli Sargent,1 Walter F Schmidt,2 Robert J Aughey,3,4 Pitre C Bourdon,5
Rudy Soria,6 Jesus C Jimenez Claros,6 Laura A Garvican-Lewis,7,8 Martin Buchheit,5
Ben M Simpson,5 Kristal Hammond,3 Marlen Kley,2 Nadine Wachsmuth,2
Christopher J Gore,7,8,9 Gregory D Roach1
ABSTRACT
Background Altitude training is used by elite athletes
to improve sports performance, but it may also disrupt
sleep. The aim of this study was to examine the effects
of 2 weeks at high altitude on the sleep of young elite
athletes.
Australian under-17 soccer team on an 18-day (19-
night) training camp in Bolivia, with six nights at near
sea level in Santa Cruz (430 m) and 13 nights at high
altitude in La Paz (3600 m). Sleep was monitored using
polysomnography during a baseline night at 430 m and
three nights at 3600 m (immediately after ascent,
1 week after ascent and 2 weeks after ascent). Data
were analysed using effect size statistics.
Results All results are reported as comparisons with
baseline. Rapid eye movement (REM) sleep was likely
lower immediately upon ascent to altitude, possibly
lower after 1 week and similar after 2 weeks. On all
three nights at altitude, hypopneas and desaturations
were almost certainly higher; oxygen saturation was
almost certainly lower; and central apnoeas, respiratory
arousals and periodic breathing were very likely higher.
The effects on REM sleep were common to all but one
participant, but the effects on breathing were specific to
only half the participants.
Conclusions The immediate effects of terrestrial
altitude of 3600 m are to reduce the amount of REM
sleep obtained by young elite athletes, and to cause
50% of them to have impaired breathing during sleep.
REM sleep returns to normal after 2 weeks at altitude,
but impaired breathing does not improve.
INTRODUCTION
Altitude training is used by elite athletes from indi-
vidual and team sports in an attempt to improve
sports performance. The rationale for this type of
training is that the hypoxia of altitude can stimulate
the production of red blood cells, which in turn
can increase maximal oxygen consumption on
return to sea level.1 Although altitude training can
be beneficial, it also has risks and costs. In particu-
lar, altitude training camps are expensive,2 training
cannot be conducted at the same intensity at alti-
tude as at sea level1 3 and the athletes are suscep-
tible to illness at the start of camp due to the acute
effects of altitude4 and, later in the camp, due to
suppressed immune function.5 Furthermore, there
is some indirect evidence to indicate that altitude
training may interfere with athletes’ sleep.
Original article
Br J Sports Med: first published as 10.1136/bjsports-2013-092829 on 26 November 2013. Downloaded from http://bjsm.bmj.com/ on 31 March 2019 by guest. Protected by copyright.
Sleep is an essential component of daytime func-
tioning,6 so any intervention that potentially dis-
rupts athletes’ sleep should be closely examined.
Human sleep is comprised of rapid eye movement
(REM) sleep and non-rapid eye movement
(NREM) sleep. NREM sleep is further divided into
three stages representing a continuum from ‘light’
sleep to ‘deep’ sleep.7 REM sleep and deep sleep
are the most important stages because the former
aids mental recovery, learning and memory consoli-
dation,8 and the latter aids physical recovery and
growth.9 10 The normal composition of sleep
stages within a sleep period, that is, ‘sleep architec-
ture’, is 61% light, 16% deep, and 23% REM for
adults (aged 30 years) and 57% light, 22% deep,
and 21% REM for adolescents (aged 16 years).11
The effects of high altitude, either terrestrial or
simulated, on elite athletes’ sleep are currently
unknown. Nevertheless, comparisons of untrained
adults’ sleep at sea level and at high terrestrial alti-
tude (ie, 4559–5050 m) indicate that sleep periods
at altitude have more arousals,12–16 more wakeful-
ness13 and less deep sleep.12–15 Similarly, compared
with living at sea level, when recreational athletes
live at low and moderate simulated altitudes (ie,
2000–2650 m), their sleep periods contain more
arousals,17 more abnormal breathing,18–20 and less
deep sleep.18 These athlete studies provide a good
indication of the potential effects, but the degree to
which their results can be generalised to elite ath-
letes in high terrestrial altitude training camps over
several days is limited because the participants were
recreational athletes, the altitude was simulated and
at a low-moderate level and only acute effects were
assessed.
The aim of this study was to examine the effects
of living at high altitude for several days on the
sleep of young elite athletes who usually live at sea
level. This was achieved by assessing the sleep of
soccer players in an underage national team during
an 18-day training camp in Bolivia. Sleep periods
were monitored once at near sea level, then three
times over a 2-week period at high altitude.
METHODS
Participants
Ten male soccer players (age 15.6±0.5 years, mass
71.0±5.8 kg; mean±SD), who were all sea-level
natives and members of the Australian under-17
Soccer Team (the ‘Joeys’), volunteered to partici-
pate in the study. Originally, 12 players were
recruited to participate, but data sets were
1 of 8
 Original article
incomplete for two of them due to illness and/or equipment
failure, so these were excluded from all analyses. The study was
approved by ethics committees at the Australian Institute of
Sport and the Universidad Mayor de San Andrés. Written
informed consent was obtained from participants and their
guardians.
Protocol
In August 2012, the Joeys participated in a training camp in
preparation for the 2012 Asian Soccer Confederation under-16
Championship. The team travelled from Sydney, Australia, then
lived and trained in Bolivia for 18 days (and 19 nights)—the
first six nights at near sea level in Santa Cruz (430 m), and the
next 13 nights at high altitude in La Paz (3600 m). A general
description of the study methods, and data related to blood
gases, wellness, running performance, activity during matches
and sleep/wake behaviours, are reported in our companion
papers in this issue.2 21–25
Each participant was observed during a baseline sleep at near
sea level and three sleeps at high altitude (figure 1). Only six
sets of data acquisition equipment were available, so for each
time point, data collection occurred on two successive nights,
each with six participants. Ultimately then, data were collected
1–2 nights prior to ascent to altitude, immediately after ascent
(nights 1–2 at altitude), 1 week after ascent (nights 6–7 at alti-
tude) and 2 weeks after ascent (nights 12–13 at altitude). All
team members were accommodated in two-person hotel rooms,
so participants were paired together. Participants were required
to attend a brief prebreakfast testing session by 09:30 h each
day, but other than that they were free to chose their own bed-
times and get-up times.
Sleep was recorded using portable polysomnography equipment
(Compumedics; Victoria, Australia) with a standard montage of
electrodes. The montage included two EEGs (C4-M1, C3-M2),
two electro-oculograms (left outer canthus, right outer canthus)
and a submental electromyogram. Respiratory effort was measured
with a piezoelectric band (Compumedics; Victoria, Australia) and
oxygen saturation was measured with a pulse oximeter (Nonin
Medical; Minnesota, USA).
In the 30 min prior to bedtime, each participant had poly-
somnography electrodes applied to their face and scalp, a
respiratory band placed around their chest and a pulse oximeter
attached to their index finger. Each pair of participants was
given an electronic pager that could be used to call the research-
ers during the night if required. Once all equipment was in pos-
ition and the participants were comfortable, the lights were
turned off. The signals from each device were transmitted wire-
lessly to a laptop computer located in a separate room to be
Figure 1 Sleep study protocol. The
bottom section of the figure indicates
when participants were at near sea
level and when they were at high
altitude. The top section of the
figure indicates when participants had
their sleep monitored. Only six sets of
data acquisition equipment were
available, so for each time point, data
collection occurred on two successive
nights, each with six participants.
2 of 8
Br J Sports Med: first published as 10.1136/bjsports-2013-092829 on 26 November 2013. Downloaded from http://bjsm.bmj.com/ on 31 March 2019 by guest. Protected by copyright.
monitored overnight by the researchers. When participants
wanted to get up in the morning, they paged the researchers
and the monitoring equipment was removed.
Measures
All sleep records were blinded and then analysed in 30 s epochs
by a trained technician. Sleep stages, respiratory events, arousals
and desaturations were manually scored in accordance with
established criteria.26 For each sleep period, the following
dependent variables were calculated: time in bed (h), total sleep
time (h), sleep onset latency (min), light sleep (ie, time spent in
stage N1 or stage N2 sleep; min), deep sleep (ie, time spent in
stage N3 sleep; min), REM sleep (time spent in stage R sleep;
min), wake after sleep onset (min), sleep efficiency (ie, total sleep
time/time in bed×100; %), central apnoeas (count), hypopneas
(count), respiratory disturbance index (ie, total number of central
apnoeas and hypopneas/total sleep time; per hour), total arousals
(count), spontaneous arousals (count), respiratory arousals
(count), mean oxygen saturation (%), minimum oxygen satur-
ation (%), desaturations (count) and periodic breathing (ie, time
spent in periodic breathing/total sleep time×100; %).
Statistical analyses
Sleep architecture was compared between the baseline sleep and
the three sleeps at altitude using separate χ2 tests. For all other
comparisons between the baseline sleep and the three sleeps at
altitude, variables were log transformed to reduce bias due to
non-uniformity of error. The magnitude of the observed effects
was assessed using standardised differences (effect size statistics)
with a customised Excel-based spreadsheet.27 For each variable,
three separate probabilities were calculated using Student’s t test
to estimate the chances that the mean value at altitude was
greater, similar and lower than the mean value at baseline. For
these analyses, the hypothesised difference, that is, the smallest
worthwhile difference, was calculated as 0.5×the between-
subject SD. A relatively conservative value was used for the smal-
lest worthwhile difference (ie, 0.5 rather than the standard 0.227)
because the relationships between changes in sleep and changes
in sports performance are not yet well quantified. The resultant
probabilities were used to mechanically interpret the likelihood
that an observed effect was a true effect using the following stan-
dards: <1%, almost certainly not; 1–5%, very unlikely; 5–25%,
unlikely; 25–75%, possibly; 75–95%, likely; 95–99%, very
likely; and >99%, almost certainly. If the probability that a mean
value at altitude was greater than its corresponding mean value at
baseline and the probability that it was lower were both >5%,
then the effect was interpreted as unclear.
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immediately after ascent (χ2(2)0.3, p=0.84), 1 week after ascent
Table 1 Sleep architecture for adolescents
(χ2(2)0.5, p=0.76) and 2 weeks after ascent (χ2(2)0.0, p=0.99).
Light sleep % Deep sleep % REM sleep % On the first nights at altitude, REM sleep was likely lower
(stages N1 & N2) (stage N3) (stage R) (figure 2D); sleep efficiency (figure 2A), total sleep time (figure
Normative 57.0 22.0 21.0
2B), and deep sleep (figure 2C) were possibly lower; and wake
Baseline 50.5 27.1 22.4
after sleep onset was possibly higher than on the baseline night
Altitude-1 54.5 25.7 19.8
(table 2). These differences are indicators of poorer sleep at alti-
Altitude-2 55.5 24.7 19.8
tude than at near sea level. For all other sleep-related variables,
Altitude-3 51.0 26.1 22.9
there were no differences between sleep on the first nights at
altitude and sleep on the baseline night (table 2).
Sleep stages as a percentage of total sleep time. Data are presented for normal
adolescent sleep (normative), and for the sleep of this study’s participants during one After a week at altitude, deep sleep (figure 2C) and REM
night at near sea level (baseline) and three nights at high altitude (altitude-1, sleep (figure 2D) were possibly lower; and stage N2 sleep was
altitude-2 and altitude-3). possibly higher than on the baseline night (table 2). These dif-
ferences are indicators of poorer sleep at altitude than at near
sea level. For all other sleep-related variables, there were no dif-
RESULTS ferences between sleep after a week at altitude and sleep on the
Sleep baseline night (table 2).
The sleep architecture for the baseline sleep in this study was After 2 weeks at altitude, time in bed and deep sleep (figure 2C)
similar to the sleep architecture based on normative data for were possibly lower than on the baseline night (table 2). These
adolescents11 (χ2(2)1.0, p=0.61; table 1). Furthermore, the differences are indicators of poorer sleep at altitude than at near
sleep architecture at baseline was preserved for all three sleeps sea level. In contrast, sleep onset latency, stage N1 sleep and
monitored at high altitude (table 1), which occurred wake after sleep onset were possibly lower; and sleep efficiency

Figure 2 Characteristics of sleep for a baseline night at near sea level (BL) and three nights at high altitude (Alt-1, Alt-2 and Alt-3). In the top
section of each panel, data for each night are presented as mean (±90% CIs). Asterisks indicate the likelihood that an observed effect, that is,
difference from baseline, was a true effect: *possibly; **likely; ***very likely; ****almost certainly. In the bottom section of each panel, data are
presented as the within-group standardised changes (±90% CIs) from baseline, and the shaded area represents trivial changes.

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Table 2 Sleep, breathing, arousals and oxygen saturation for one night at near sea level and three nights at high altitude
Altitude-1 (immediately after ascent to altitude) Altitude-2 (1 week after ascent to altitude) Altitude-3 (2 weeks after ascent to altitude)
Baseline
Difference: Chances that value is Difference: Chances that value is Difference: Chances that value is
Mean Mean effect sizewith greater/similar/lower effect sizewith greater/similar/lower effect sizewith greater/similar/lower
Variable (SD) (SD) 90% CL than baseline value (%) Mean (SD) 90% CL than baseline value (%) Mean (SD) 90% CL than baseline value (%)

Time in bed (h) 9.3 (0.9) 9.0 (0.7) −0.29 −0.48;−0.10 0/96/4 9.4 (1.4) −0.02 −0.63; 0.58 7/84/9 8.7 (1.1) −0.60 −1.11;−0.08 0/37/63
Total sleep Time (h) 8.0 (0.7) 7.4 (0.8) −0.62 −0.95;−0.30 0/25/74 8.0 (1.1) −0.01 −0.59; 0.58 7/85/8 7.7 (0.9) −0.31 −0.78; 0.16 1/75/24
Sleep onset latency (min) 18 (8) 14 (7) −0.22 −0.56; 0.11 0/92/8 23 (19) 0.12 −0.39; 0.63 10/87/3 12 (8) −0.58 −0.94;−0.22 0/35/65
Stage N1 (min) 26 (13) 26 (13) 0.12 −0.31; 0.55 7/92/1 25 (10) −0.01 −0.61; 0.59 8/84/8 20 (7) −0.39 −0.88; 0.10 0/65/35
Stage N2 (min) 216 (28) 215 (37) −0.04 −0.27; 0.19 0/100/0 245 (73) 0.42 −0.29; 1.13 42/56/2 216 (41) −0.04 −0.56; 0.47 4/89/7
Stage N3 (min) 130 (19) 114 (27) −0.63 −1.02;−0.24 0/28/72 117 (29) −0.50 −1.00; 0.00 0/50/50 120 (24) −0.39 −0.79;−0.01 0/71/29
Stage R (min) 107 (25) 88 (19) −0.82 −1.33;−0.32 0/14/86 93 (21) −0.59 −1.28; 0.10 1/40/59 106 (17) −0.01 −0.52; 0.50 5/89/6
Wake after sleep onset (min) 64 (39) 81 (34) 0.58 −0.05; 1.21 59/40/1 59 (32) −0.04 −0.77; 0.69 10/76/14 47 (31) −0.51 −1.17; 0.16 1/48/51
Sargent C, et al. Br J Sports Med 2013;47:i86–i92. doi:10.1136/bjsports-2013-092829

Sleep efficiency (%) 86 (5) 82 (6) −0.56 −1.21; 0.09 1/42/57 86 (5) 0.03 −0.78; 0.83 15/71/13 89 (4) 0.57 0.04; 1.09 59/41/0
Respiratory disturbance Index (h−1) 1 (1) 30 (39) 1.19 0.67; 1.71 98/2/0 45 (57) 1.34 0.78; 1.90 100/0/0 34 (41) 1.26 0.73; 1.79 99/1/0
Central apnoeas (count) 8 (7) 142 (216) 0.70 0.25; 1.16 78/21/0 285 (451) 0.78 0.19; 1.37 80/20/0 177 (231) 0.86 0.36; 1.34 89/11/0
Hypopneas (count) 2 (2) 92 (101) 1.81 1.26; 2.37 100/0/0 110 (114) 1.95 1.40; 2.50 100/0/0 98 (109) 1.92 1.45; 2.39 100/0/0
Periodic breathing (%) 0 (0) 13 (18) 0.91 0.38; 1.44 90/9/0 24 (32) 0.99 0.33; 1.65 90/10/0 21 (28) 0.95 0.31; 1.58 88/11/0
Total arousals (count) 88 (27) 143 (68) 0.58 0.27; 0.90 68/32/0 293 (303) 1.07 0.27; 1.86 89/11/0 144 (92) 0.53 0.11; 0.94 55/45/0
Spontaneous arousals (count) 86 (28) 83 (44) −0.20 −0.64; 0.24 1/87/12 75 (76) −0.59 −1.17;−0.01 0/39/61 72 (44) −0.47 −1.05; 0.12 1/53/46
Respiratory arousals (count) 2 (3) 60 (84) 0.89 0.47; 1.31 94/6/0 155 (290) 0.97 0.40;1.53 92/8/0 72 (108) 0.90 0.38; 1.42 90/10/0
Mean SpO2 (%) 97 (1) 82 (3) −5.84 −6.52;−5.16 0/0/100 86 (3) −4.06 −4.47;−3.42 0/0/100 88 (1) −3.41 −3.64;−3.18 0/0/100
Minimum SpO2 (%) 93 (2) 74 (4) −3.73 −4.23;−3.23 0/0/100 77 (6) −3.13 −3.98;−2.28 0/0/100 80 (3) −2.37 −2.71;−2.03 0/0/100
Desaturations >3% (count) 3 (3) 214 (283) 1.55 1.07; 2.03 100/0/0 329 (407) 1.79 1.28; 2.29 100/0/0 256 (305) 1.75 1.30; 2.20 100/0/0
Variables related to sleep, breathing, arousals and oxygen saturation for one night at near sea level (baseline) and three nights at high altitude (altitude-1, altitude-2 and altitude-3). For each night, data are presented as means (±SD). For each night at
altitude, data are also presented as standardised differences from baseline (ie, effect size with 90% CL), and the chances that an observed value is greater/similar/lower than the corresponding baseline value are given. Baseline occurred 1–2 nights before
ascent to high altitude, altitude-1 occurred 1–2 nights after ascent, altitude-2 occurred 6–7 nights after ascent and altitude-3 occurred 12–13 nights after ascent.

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 Original article

(figure 2A) was possibly higher after 2 weeks at altitude than on
the baseline night (table 2). These differences are indicators of
better sleep at altitude than at near sea level. For all other
sleep-related variables, there were no differences between sleep
after 2 weeks at altitude and sleep on the baseline night (table 2).
Respiratory events and periodic breathing
At baseline, none of the participants exhibited any signs of dis-
ordered breathing during sleep and there was almost no respira-
tory disturbance. However, ascending to altitude had a
profound negative effect on breathing during sleep. Compared
with baseline, the respiratory disturbance index (figure 3A) was
very likely higher on the first nights at altitude and almost cer-
tainly higher after 1 and 2 weeks at altitude (table 2). On all
three nights monitored at altitude, hypopneas were almost cer-
tainly higher; and central apnoeas and periodic breathing
(figure 3B) were likely higher than on the baseline night (table
2). There were marked individual differences in susceptibility to
periodic breathing. Half of the participants exhibited periodic
breathing on all three nights monitored at altitude, while the
Br J Sports Med: first published as 10.1136/bjsports-2013-092829 on 26 November 2013. Downloaded from http://bjsm.bmj.com/ on 31 March 2019 by guest. Protected by copyright.
other half did not exhibit periodic breathing on any of these
nights (see figure 4 for an example). As a result of this finding,
the athletes’ data were split into two groups, and the sleep archi-
tecture of these groups was compared for all four sleeps at near
sea level and altitude using χ2 tests. There was no difference in
sleep architecture between the two groups at near sea level
(χ2(2)0.1, p=0.95), on the first nights at altitude (χ2(2)0.1,
p=0.95), after 1 week at altitude (χ2(2)0.1, p=0.96) or after
2 weeks at altitude (χ2(2)0.0, p=0.98).
Arousals
Compared with baseline, total arousals were possibly higher on
the first night at altitude, likely higher after 1 week at altitude
and possibly higher after 2 weeks at altitude (table 2). These dif-
ferences were not due to changes in spontaneous arousals,
which were possibly lower after 1 and 2 weeks at altitude com-
pared with baseline, but rather due to the likely increases in
respiratory arousals (figure 3C) for all sleeps at altitude com-
pared with baseline (table 2).

Figure 3 Characteristics of breathing, arousals, and oxygen saturation for a baseline night at near sea level (BL) and three nights at high altitude
(Alt-1, Alt-2 and Alt-3). In the top section of each panel, data for each night are presented as mean (±90% CIs). Asterisks indicate the likelihood
that an observed effect, that is, difference from baseline, was a true effect: *possibly; **likely; ***very likely; ****almost certainly. In the bottom
section of each panel, data are presented as the within-group standardised changes (±90% CIs) from baseline, and the shaded area represents
trivial changes.

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 Original article
Figure 4 Examples, from one
participant, of the respiratory effort
and oxygen saturation associated with
normal breathing during sleep at near
sea level (A) and severe disordered
breathing during sleep at high altitude
(B).
Oxygen saturation
Compared with the baseline sleep, mean oxygen saturation
(figure 3D) and minimum oxygen saturation were almost cer-
tainly lower; and desaturations were almost certainly higher for
all sleeps at altitude (table 2).
DISCUSSION
Sleep
Exposure to high altitude caused some, but not major, disrup-
tion to the athletes’ sleep. The main aspect of sleep that was
affected was REM sleep, which was lower on the first nights at
altitude (88 min) than at near sea level (107 min), improved
after 1 week (93 min) and returned to its baseline level after
2 weeks (106 min; figure 2). This type of disruption in the early
days of a camp could be harmful, particularly with young ath-
letes, because losing REM sleep can impair learning and
memory consolidation.8 These results differ markedly from
those of previous studies, which have found that exposure to
high altitude substantially reduces, or even eliminates, deep
sleep and/or REM sleep immediately after ascent.12–15 The true
explanation(s) for why altitude exposure was less disruptive to
sleep in this study compared with previous studies cannot be
known for certain, but there are some important differences
between the studies that may be relevant. First, the previous
studies were conducted under more extreme conditions than
this study, as they occurred at higher altitudes (ie, ∼5000 m),
and in some cases participants had to sleep in tents or huts in
subzero ambient temperatures. Second, the participants in the
previous studies were considerably older (ie, mid-30 s) than in
this study, and they were not elite athletes.
Disordered breathing
None of the athletes exhibited any signs of disordered breathing
during sleep at near sea level, but immediately upon ascent to
altitude, there was a marked increase in the number of central
apnoeas and hypopneas, episodes of periodic breathing emerged
and oxygen saturation was greatly reduced (figure 3). These
indicators of disordered breathing during sleep had not
improved after 2 weeks at altitude. The acute effects of
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terrestrial altitude on disordered breathing during sleep have
been reported previously, albeit in older participants,14 16 but
this is the first study to show that these effects persist for at least
2 weeks. The 10 athletes in this study were split into two equal
groups based on the degree to which their breathing during
sleep was impaired: five of them were severely affected, and the
other five were unaffected, on all three nights of testing at alti-
tude. This is consistent with previous studies of sleep at altitudes
of 3800 and 3900 m, which found severe disordered breathing
in three of six participants28 and 12 of 18 participants,14
respectively. The results of this study, and one previous study,14
indicate that the presence/absence of periodic breathing does
not affect sleep architecture. The occurrence of disordered
breathing during sleep at altitude may be due to
hypoxia-induced instability in ventilatory control,29 30 so indi-
vidual differences in susceptibility to this instability31 32 pro-
vides a possible explanation for the bifurcation of the sample in
this study and others.
Arousals and fragmentation
The athletes had very few arousals associated with respiratory
events during sleep at sea level (2), but this dramatically
increased immediately on ascent to altitude (60), increased again
after 1 week at altitude (155), and was still elevated after
2 weeks at altitude (72). It was beyond the scope of this study to
determine whether the fragmentation of sleep caused by arou-
sals was of any functional significance, but even in the presence
of otherwise normal sleep architecture, frequent arousals can be
harmful. For example, in experimental studies in which an audi-
tory tone is used to induce arousals and fragment sleep without
reducing the amount of deep sleep or REM sleep, the levels of
cognitive impairment, mood disturbance and daytime sleepiness
are similar to those observed following a night of total sleep
deprivation.33 34 It is unlikely that participants in this study
would have experienced this degree of impairment, given that
their arousals during sleep at altitude were less frequent (ie,
every 2–3 min) than arousals during sleep in these experimental
studies (ie, every 30–60 s), but there may have been some
impairment nonetheless.
Sargent C, et al. Br J Sports Med 2013;47:i86–i92. doi:10.1136/bjsports-2013-092829

Limitations
This study had two main limitations, neither of which was particu-
larly serious. First, the baseline sleeps at near sea level occurred 4–5
nights after travelling from Australia to Bolivia (a time zone change
of 10 h to the east), so it is possible that the athletes’ body clocks
had not fully adjusted before these assessments occurred. However,
the athletes followed a schedule of sunlight exposure/avoidance to
facilitate adjustment to the new time zone, based on the principles
of circadian physiology,35 and ultimately their baseline sleep was
similar to, if not better than, normal sleep for adolescents. Second,
to minimise the athletes’ potential discomfort, the montage of
sleep monitoring equipment that was employed did not include a
sensor to measure airflow. The absence of an airflow sensor meant
that central apnoeas/hypopneas were identified based on respira-
tory effort alone, rather than respiratory effort and airflow.26 This
is a reasonable approach, given that it is unlikely that airflow could
be present in the absence of respiratory effort. Furthermore, it was
not possible to identify obstructive apnoeas/hypopneas, but these
were unlikely to have occurred given that none of the athletes had
a history of obstructive sleep apnoea and altitude exposure does
not typically cause obstructive events.16
CONCLUSIONS
This is the first study to examine the effects of high altitude on
the sleep of young elite athletes. The immediate effects of alti-
tude are to cause a general reduction in the amount of REM
sleep obtained, and to severely disrupt breathing during sleep
for half the athletes. There is some recovery in REM sleep after
1 week, and after 2 weeks it has returned to normal. In contrast,
disordered breathing during sleep does not improve during
2 weeks of exposure to altitude. Future studies should examine
whether or not breathing abnormalities during sleep at high alti-
tude, and the accompanying sleep fragmentation, affect the effi-
cacy of altitude training for young elite athletes.
What are the new findings?
▸ High altitude reduces rapid eye movement (REM) sleep in
elite young athletes immediately on ascent. REM sleep
improves after 1 week at altitude, and returns to normal
after 2 weeks.
▸ High altitude causes severe disordered breathing in 50% of
elite young athletes immediately on ascent. Disordered
breathing does not improve after 2 weeks at altitude.
How might it impact on clinical practice in the near
future?
Elite young athletes participating in live high, train low camps
with simulated altitude should wear respiratory bands and/or
pulse oximeters during their first few sleeps. If an athlete has
disordered breathing and their daytime well-being and/or
performance is also poor, then they may get more benefit from
the camp if they sleep at sea level.
Acknowledgements The authors would like to thank the partner organisations2
and the Australian Research Council for their financial support; and the team’s staff
and players for their cooperation and assistance.
Sargent C, et al. Br J Sports Med 2013;47:i86–i92. doi:10.1136/bjsports-2013-092829
Original article
Br J Sports Med: first published as 10.1136/bjsports-2013-092829 on 26 November 2013. Downloaded from http://bjsm.bmj.com/ on 31 March 2019 by guest. Protected by copyright.
Contributors CS and GDR were involved in the conception and design,
acquisition, analysis and interpretation of data, drafting the article, and approved the
final version of the article. WFS was involved in the conception and design,
acquisition of data, critical revision of the article for important intellectual content,
and approved the final version of the article. RJA was involved in the analysis and
interpretation of data, critical revision of the article for important intellectual content
and approved the final version of the article. PCB, BMS, MK and NW were involved
in the acquisition of data, critical revision of the article for important intellectual
content and approved the final version of the article. RS, JCJC and LAG-L were
involved in the acquisition of data, critical revision of the article for important
intellectual content and approved the final version of the article. MB was involved in
the acquisition, analysis and interpretation of data, critical revision of the article for
important intellectual content and approved the final version of the article. KH was
involved in the acquisition of data, critical revision of the article for important
intellectual content and approved the final version of the article. CJG was involved
in the conception and design, critical revision of the article for important intellectual
content and approved the final version of the article.
Funding Australian Research Council, Australian Institute of Sport, Victoria
University, ASPIRE Zone Foundation.
Competing interests None.
Ethics approval Australian Institute of Sport Human Research Ethics Committee.
Provenance and peer review Not commissioned; externally peer reviewed.
Open Access This is an Open Access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which
permits others to distribute, remix, adapt, build upon this work non-commercially,
and license their derivative works on different terms, provided the original work is
properly cited and the use is non-commercial. See: http://creativecommons.org/
licenses/by-nc/3.0/
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ventilatory sensitivity to hypoxia. Resp Physiol 1983;52:281–301.
33 Bonnet MH. Performance and sleepiness as a function of frequency and placement
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34 Levine B, Roehrs T, Stepanski E, et al. Fragmenting sleep diminishes its recuperative
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BrJ7 Sports Med 1997;31:183-190
Physiological implications of altitude training for
endurance performance at sea level: a review
Damian M Bailey, Bruce Davies
Summary
Acclimatisation to environmental hypoxia initi-
ates a series of metabolic and musculocardio-
respiratory adaptations that influence oxygen
transport and utilisation. Whilst it is clear that
adequate acclimatisation, or better still, being
born and raised at altitude, is necessary to
achieve optimal physical performance at alti-
tude, scientific evidence to support the poten-
tiating effects after return to sea level is at
present equivocal. Despite this, elite athletes
continue to spend considerable time and
resources training at altitude, misled by subjec-
tive coaching opinion and the inconclusive
findings of a large number of uncontrolled
studies. Scientific investigation has focused on
the optimisation of the theoretically beneficial
aspects of altitude acclimatisation, which in-
clude increases in blood haemoglobin concen-
tration, elevated buffering capacity, and im-
provements in the structural and biochemical
properties of skeletal muscle. However, not all
aspects of altitude acclimatisation are benefi-
cial; cardiac output and blood flow to skeletal
muscles decrease, and preliminary evidence
has shown that hypoxia in itself is responsible
for a depression of immune function and
increased tissue damage mediated by oxidative
stress. Future research needs to focus on these
less beneficial aspects of altitude training, the
implications of which pose a threat to both the
fitness and the health of the elite competitor.
Paul Bert was the first investigator to show
that acclimatisation to a chronically reduced
inspiratory partial pressure of oxygen (PIo,)
invoked a series of central and peripheral
adaptations that served to maintain adequate
tissue oxygenation in healthy skeletal muscle,'
physiological adaptations that have been subse-
quently implicated in the improvement in exer-
cise performance during altitude acclimatisa-
tion. However, it was not until half a century
later that scientists suggested that the additive
stimulus of environmental hypoxia could po-
tentially compound the normal physiological
adaptations to endurance training and acceler-
ate performance improvements after return to
sea level. This has stimulated an exponential
School of Applied increase in scientific research, and, since 1984,
Sciences, University of 22 major reviews have summarised the physio-
Glamorgan, logical implications of altitude training for both
Pontypridd, aerobic and anaerobic performance at altitude
Mid-Glamorgan, and after return to sea level. Of these reviews,
United Kingdom
D M Bailey only eight have specifically focused on physical
B Davies performance changes after return to sea level,2-9
the most comprehensive of which was recently
Correspondence to: written by Wolski et al. 9
D M Bailey.
Few reviews have considered the potentially
Accepted for publication less favourable physiological responses to
8 May 1997 moderate altitude exposure, which include
183
decreases in absolute training intensity,'0 de-
creased plasma volume," depression of haemo-
poiesis and increased haemolysis,12 increases in
sympathetically mediated glycogen depletion
at altitude,'3 and increased respiratory muscle
work after return to sea level.'4 In addition,
there is a risk of developing more serious medi-
cal complications at altitude, which include
acute mountain sickness, pulmonary oedema,
cardiac arrhythmias, and cerebral hypoxia. 5
The possible implications of changes in im-
mune function at altitude have also been
largely ignored, despite accumulating evidence
of hypoxia mediated immunosupression."
In general, altitude training has been shown
to improve performance at altitude, whereas no
unequivocal evidence exists to support the
claim that performance at sea level is improved.
Table 1 summarises the theoretical advantages
and disadvantages of altitude training for sea
level performance.
This review summarises the physiological
rationale for altitude training as a means of
enhancing endurance performance after return
to sea level. Factors that have been shown to
affect the acclimatisation process and the sub-
sequent implications for exercise performance
at sea level will also be discussed.
Studies were located using five major data-
base searches, which included Medline, Em-
base, Science Citation Index, Sports Discus,
and Sport, in addition to extensive hand
searching and cross referencing. All published
English studies, dating back from the present
day to 1956, that included physiological meas-
urements during exercise before and after
hypoxic training were incorporated in the over-
all analysis. Ninety one investigations were
selected, which included 772 hypoxically
trained experimental and 209 normoxically
trained control subjects.
The investigations were subdivided accord-
ing to whether a normoxically trained control
group was incorporated into the experimental
design. Other classifications were made de-
pending on the characteristics of the hypoxic
stimulus, which included type (normobaric or
hypobaric hypoxia; continuous or intermit-
tent), duration, and magnitude (calculated
ambient Po,), and timing of physiological test-
ing after the descent to sea level.
The continued popularity of altitude training
has been influenced by two factors. Firstly,
hypoxia in itself increases blood haemoglobin
(Hb) concentration, which has been shown to
improve endurance performance. Secondly,
several of the best endurance runners in the
world have originated from East African coun-
tries that are based at altitude (1500-2000 m).
Is it possible that either living and/or training at
184 Bailey, Davies

Table 1 Physiological changes during altitude acclimatisation in native lowlanders; time from athletes who were born and raised at a
course and theoretical implications for exercise performance at sea level median altitude of 2000 m above sea level. This
Response phenomenon has prompted several compara-
Physiological advantages time Physiological disadvantages Response time tive investigations into what, if any, physiologi-
Increased free fatty acid Weeks Increased ventilation Immediate
cal adaptations mediated by hypoxia could
mobilisation contribute to their superiority in distance run-
Increased haemoglobin Days Decreased cardiac output Days ning events. Much interest has focused on the
Increased capillarity Months/ Decreased blood flow Days four steps of the oxygen transport system,
years?
Increased oxidative Weeks Immunosupression Immediate?/ namely alveolar ventilation, lung diffusion, cir-
enzyme activity days culatory oxygen transport, and tissue oxygen
Increased mitochondrial Weeks Increased oxidative stress and tissue Immediate extraction. Studies have shown that the native
volume damage
Increased dehydration Immediate highlander is characterised by a larger pulmo-
Jet lag Immediate nary diffusion capacity32 and adaptations in the
Decreased training intensity Immediate structural and metabolic organisation of skel-
Acute mountain sickness Days
Sunburn due to increased ultraviolet Immediate etal muscle that result in a tighter coupling
B (290-320nm) between ATP hydrolysis and oxidative
Catecholamine mediated glycogen Days-weeks phosphorylation.33 These are the major factors
depletion
Increased haemolysis Weeks that facilitate oxygen transport and utilisation.
The significance of these adaptations has been
altitude may contribute to their running elucidated in a series of investigations that have
success? reported higher values for VO2MAXI,34 power
output,35 arterial oxygen saturation,36 and cer-
Physiological rationale for altitude ebral oxygen delivery37 during maximal exercise
training and decreased blood lactate33 3 and ammonia
AUTOLOGOUS BLOOD REINFUSION AND
concentrations38 for a given submaximal work
ENDURANCE PERFORMANCE
rate.
One of the most documented physiological To what extent these physiological adapta-
adaptations to a reduced Ppo2 is the increased tions are acquired as the result ofinheritance or
release of erythropoietin, which causes a hypobaric hypoxia is not well defined. The
transient increase in red blood cell mass.'7 The influence of genetic factors on quantitative
implications of secondary polycythaemia to oxygen transport was recently investigated in a
both submaximal and maximal indices of unique study by Beall et al.39 They identified a
endurance performance have been clearly major gene that enhances arterial oxygen satu-
shown by studies that have artificially induced ration in sedentary Tibetan natives. The physi-
erythrocythaemia after either autologous blood ological significance of this was shown by
reinfusion' or subcutaneous injections of Niermeyer et al,40 who concluded that genetic
recombinant human erythropoietin.'9 20 Table adaptations to hypobaric hypoxia resulted in
2 summarises the major research findings. It improved oxygenation and conferred resistance
has been reported that absolute maximal to subacute infantile mountain sickness. These
oxygen uptake (Vo2MAx) values are increased adaptations were more pronounced in a cohort
by about 200 ml/min per g/dl increase in Hb, of Tibetan newborns whose ancestors have
irrespective of the methods by which poly- resided at altitude for 50 000 to 100 000 years,
cythaemia is induced.2' in comparison with Han newborns whose
However, the use of blood doping as an ancestors had resided at altitude for only 45
ergogenic aid is considered unethical and years.4' In general, these findings would suggest
potentially dangerous and is banned by the that a lifetime or perhaps generations of
International Olympic Committee.22 altitude exposure are responsible for the
biological distinctiveness of the high altitude
PHYSIOLOGICAL ADAPTATIONS OF THE NATIVE
population.
HIGHLANDER: A SUPERIOR ATHLETE?
Figure 1 illustrates the apparently dispropor- Altitude training and sea level endurance
tionate running success of the native high- performance in native lowlanders
lander. This figure represents data obtained Table 3 summarises the effects of altitude
training on sea level endurance performance.
The weight of scientific evidence does not sup-
Table 2 Effects of autologous blood reinfusion on Vo2 MAX port the potentiating effects of altitude train-
ing. However, it is becoming clearer that a
Volume of blood Change in Hb after Change in Vo2 MAX after number of methodological deficiencies may
Authorlreference reinfused (ml) reinfusion (%) reinfusion (%)
preclude the potential synergistic effects of
Ekblom'9 1350 +9* +8* hypoxia and physical exercise, the physiological
Celsing2' 2250 +11 +7**
Buick23 900 +8** +5** implications of which will be discussed in the
Spriet24 1200 NR +7* following sections.
Williams25 920 +7** NR
Goforth26 760 +4* +11**
Robertson27 750 +28* +13* Intensity and duration of the hypoxic
Robertson28 475 +16* +10* stimulus and associated haematological
Thompson29 1000 +12* +11*
Sawka30 600 +10* +11* adaptation
Robertson31 475 + 16* +10** There is still much controversy about the opti-
mal altitude and duration required for athletes
*
Significantly different from before reinfusion (P < 0.05). to train in an attempt to optimise endurance
**Significantly different from before reinfusion (P < 0.01).
NR, not reported. performance at sea level. Much attention has
Altitude training for endurance performance at sea level 185

m Rest of the World can train the better. However, other factors that
m Native Highlander inhibit exercise performance are exacerbated
with a reduction in Po2. Acute mountain
100
sickness presents at altitudes above 2000 to
0
3000 M,77 with the possibility of the elite athlete
.ra
90 suffering physiological symptoms at even lower
80
altitudes.'5 Prolonged exposure to altitudes
X 70 above 4500 m has been shown to result in a
E reduction in muscle mass, the underlying
60
physiological mechanisms for which have been
CL50 recently reviewed by Kayser.78 Finally, the
0 40 effects of training at a lower Po, may result in a
0
W-
reduction in work rate, so that detraining may
30-
override the potential benefits of altitude
C 20 acclimatisation.'8
10.
?L Hypoxia and detraining
A recent study has shown that VO2MAX is
-~~~~~~1 °° ep° li
°° se bt significantly reduced at an altitude as low as
610 m above sea level in elite endurance
athletes.80 This is a phenomenon peculiar to
Specialist distance about 50% of trained subjects, with VoMAx
Figure 1 Percentage of Olympic medals for middle and long distance running events won values of above 65 ml/kg per min or 4
by native highlanders since 1960. litres/min.8' These elite athletes develop more
severe levels of arterial hypoxaemia during
Table 3 Effects of hypoxic training on sea level endurance performance maximal and submaximal exercise than seden-
tary controls both under normoxic and hypoxic
Hypoxic Exposure
Time tested
after altitude Submaximal Change in Vo2 Control
conditions.82 83 Several mechanisms have been
stimulus Altitude (m) time (days) (days) improvement uA.x (%) group proposed to explain these findings, which
include hypoventilation, venoarterial shunting,
Potentiating effects ventilation-perfusion inequality, and an
CH42 1300-2500 28 1 Yest +4t No alveolar-capillary diffusion limitation.84 85
CH43 1900 21 1/14 Yest NS/NS No These observations led early investigators to
CH44 2100-2700 14 2 Yest NS No
CH45 2300 23 3/21 Yest +8t/+ 10t No hypothesise that altitude exposure may result
CH46 2500 28 7 ND +6t No in a detraining response.79 Daniels and
IH47 3049-4268 23 3-4 Yest NS No Oldridge57 have shown the importance of train-
CH48 3800 35 14 ND +14t No
IH49 4020 21/28 1 Yest +8t/+26t No ing intensity at altitude and its effects on sea
CH50 1250-2500 28 7 Yest +4t Yes level performance. They suggested that inter-
IH5 2300 21-28 1 Yest NS Yes mittent exposures to altitudes of 2300 to 3300
IH52 2300 28 1-2 Yest ND Yes
IH53 4000 70 1 Yest NS Yes m and sea level optimised the balance between
No potentiating effects hypoxic acclimatisation and training intensity.
CH45 2300 14 1 No NS No Despite the experimental limitations of a single
CH54 1695-2700 7 4 ND NS No
CH55 2240 20 4/22 ND +6/+9* No group design, two world records and 12
CH56 2300 42 4-5 No NS No personal best times were recorded by athletes
CH57 2300 70 5 ND NS No
CH58 2800 10 2-4 No +7* No on return to sea level, which presented a
CH59 3090 17 1 ND NS No reasonable endorsement for such an approach.
CH60 3110 21 7 ND -5* No However, from our experience, it is equally
CH61 4000 48-63 2-15 No NS No
IH62 4000 21 1 ND NS No possible to have expected similar improve-
CH38 2000 14 6/12 ND NS/NS Yes ments in a control group training at sea level.64
CH63 1600-1800 18-28 7 ND NS Yes The detraining effect induced during
CH64 1640 28 20 No NS Yes
CH65 1700-2000 28 7 No NS Yes chronic exposure to hypobaric hypoxia has
CH66 2300 21 1 No NS Yes been quantified in a sequence of studies by
IH67 2250 28 1 ND + 17.5* Yes Levine et al.42 50 68 In their most recent study,50
IH67 3450 28 1 ND +10.0* Yes
IH68 2500 28 1 No NS Yes 39 competitive runners were randomly as-
IH69 2500 35 1 ND NS Yes signed to four weeks of (a) living high (2500 m)
CH70 2600 11 1 ND NS Yes and training low (1250 m), (b) living high
IH71 3100 19 6 No NS Yes
IH72 3345 42 1 ND NS Yes (2500 m) and training high (2500 m), or (c)
IH73 4020 15 1 ND NS Yes living low (150 m) and training low (150 m).
IH74 4100-5700 21 1 ND NS Yes
They showed that, although VO2MAX values
CH75 4300 28 1-5 ND NS Yes
significantly improved 5 km race performance
CH, Chronic hypobaria; IH, intermittent hypobaria; ND, no data. times by 4% in the two altitude trained groups,
*
Level of significance not reported the running velocity that corresponded to
t Significantly different from pre-altitude value (P<0.05).
t Significantly different from pre-altitude value (P<0.01). Vo2MAx and the ventilatory threshold at sea
NS, not significantly different from pre-altitude value (P>0.05). level were significantly improved only in the
group that lived high and trained low. An un-
focused on the erythropoietic response to usual finding was that 5 km performance time
hypoxia and subsequent haematological adap- was 31 seconds slower in the sea level control
tation. Considering the inverse relationship group, which would suggest that the training
between Po, and resting Hb concentration, 76 it stimulus was not absolutely controlled during
would seem logical that the higher the athlete the experimental period. Nevertheless, it was
186
concluded that the potentiating effects of
altitude training were due to a high altitude
acclimatisation effect (improved haematology)
and a low altitude training effect (increased
training intensity). Thus the authors advocated
the practice of living high and training low as
the optimal approach to altitude training. This
has popularised the use of "altitude houses"
recently developed in Finland which are
portable hypobaric chambers used by elite ath-
letes, who alternate living and sleeping at
simulated altitude with normobaric training.86
However, the effectiveness of this procedure
should at present be considered equivocal, and
further scientific investigation is warranted to
endorse this approach to altitude training.
Concept of a critical Po2 and
haematological adaptation
Few athletes can afford the costs inherent in a
"live high, train low" approach to altitude
training. Therefore is it possible that a "thresh-
old" altitude exists that optimises the benefits
of haematological acclimatisation and mini-
mises the negative effects of detraining? Weil et
a/87 have presented the most comprehensive
evidence indicating the existence of such a
threshold, albeit in sedentary highland natives
(B Levine, personal communication). They
identified a biphasic relationship between the
arterial partial pressure of oxygen (Pao,) and
red blood cell mass, and shown a clear
inflection point at a "critical" Pao, of 67 mm
Hg, equivalent to an interpolated arterial
oxygen saturation of 92%. This point corre-
sponds to the steeper portion of the oxygen-Hb
dissociation curve. The equivalent Po, would
equate to about 135 mm Hg, which is compa-
rable with an altitude of 2200-2500 m above
sea level required to stimulate sufficient
haemopoiesis at rest to influence endurance
performance.4 However, it has been shown that
the decrement in Vo2MAX measured in hypo-
baric hypoxia is directly proportional to
Volv02mxmeasured in normoxia.88 This would
suggest that elite athletes are more prone to
developing arterial hypoxaemia and may gain
more benefit haematologically by training at
lower altitudes in comparison with sedentary
controls. This contention was supported by
Ingjer et al,4" who showed that three weeks of
altitude training at 1900 m in elite cross coun-
try skiers was sufficient to elevate Hb by 5%
(P<0.02) and decrease blood lactate concen-
tration during a standardised submaximal test,
despite no changes in VO2MAX. However, it
should be noted that these authors did not
measure their subjects' plasma volumes, and
their comments that the polycythaemia was
independent of a haemoconcentration remains
only speculative. The scarcity of training stud-
ies conducted at moderate altitudes of 1500 to
2000 m in elite athletes does not allow
definitive conclusions to be made.
Optimal duration
Few data are available on the optimal time an
athlete should spend training at altitude. On
the basis of subjective coaching opinion as
opposed to objective scientific evidence, it
Bailey, Davies
would appear that three weeks are sufficient to
gain a performance advantage at sea level.89
However, the longer the duration of the
hypoxic stimulus the greater the erythropoietic
response and associated haematological
adaptation.'7 This was shown by Berglund,90
who summarised the haematological changes
during previous altitude training studies con-
ducted between 1829 and 3048 m. He
identified a "true" increase in Hb concentra-
tion of 1% per week, which was independent of
a haemoconcentration. Thus, assuming that
the detraining response could be minimised
and polycythaemia did not approach patho-
logical values, the longer the athlete spends at
altitude, the greater the potential benefit for
endurance performance.
Iron status during altitude training
Hypoxia in itself increases iron demand and
mobilisation,9 92 such that endurance athletes
training at altitude may be prone to iron
deficiency. Lack of this critical erythropoietic
factor has been shown to inhibit complete hae-
matological adaptation.93 Despite its im-
portance, few studies have actually reported
iron status of athletes during their hypoxic
exposure. Suboptimal iron stores may account
for the vast majority of training studies that
have failed to show increases in Hb concentra-
tion and endurance performance on return to
sea level after the hypoxic exposure. The
differences in iron status may also characterise
the highly individualised haematological re-
sponses observed during altitude training.43
Interval between descent and event
There is some evidence to suggest that endur-
ance performance is affected by the timing of
the descent to sea level after a sojourn to
altitude. The general consensus amongst top
coaches would suggest that endurance per-
formance is optimised after 14 days at sea level
after a bout of altitude training,89 yet there is no
scientific evidence to support this claim.
Suslov94 characterised the undulating nature of
endurance performance after altitude training.
His research was based on over 1000 competi-
tive track results obtained from middle and
long distance runners after different periods of
altitude training (1300-2500 m) and repeated
sea level Vo2MAX tests conducted after training
at 1800 m. He identified a decrease in compe-
tition performance during the first two days at
sea level and the first phase of enhanced work
capacity occurring between days 3 and 7,
followed by a decrease between days 8 and 10.
Performance was shown to continue to im-
prove between days 12 and 13, with the best
results achieved on days 18 to 20. He also
identified an additional upsurge in perform-
ance between days 36 and 48 after altitude. He
failed to identify the physiological mechanisms
responsible for this phenomenon.
Few studies have tested subjects on more
than one occasion after return to sea level.
Asahina et al55 and Faulkner et at" did not show
any significant changes in VoMAX values after
either 3 or 22 days at sea level. Ingjer et at"
showed that after a group of elite cross country
Altitude training for endurance performance at sea level
80
M Control group
to
M No control group
70 k
._
H-_
_-
_ trol group. This makes it impossible to
30
.E
_-
n 1 _-
20
.
I I
..,JJ OR ,S\9", flocpb ,e
Figure 2 Number of hypoxic training studies conducted with or without a normoxical ly
trained control group since 1950.
skiers had trained for three weeks at an altit ude
of 1900 m, submaximal blood lactate val ues
were lower than pre-altitude values on da Y 1
but not day 14 at sea level. The auth ors
concluded that a 0.8 g/dl increase in Hb
concentration measured on day 1 was resp on-
sible for the observed improvement in s ub-
maximal exercise. However, their failure to
quantify plasma volume and blood fllow
changes weakens the validity of their haemaLto-
logical findings. Svedenhag et al" studie(d a
group of Swedish middle distance runners vvho
trained for a period of two weeks at altiti ude
(2000 m) and were tested after 6 and 12 dlays
on return to sea level. They did not identify any
significant changes in VoimAx, maximal oxylgen
deficit, and submaximal blood lactate val[ues
compared with pre-altitude values or betw een
days 6 and 12 at sea level. However, t]hey
showed a significant reduction in heart r ate,
Borg rating of perceived exertion, and plas,ma
ammonia concentration during a standarditsed
submaximal treadmill test, which was m ore
apparent after 12 days at sea level.
The physiological mechanisms responsi ible
for these subtle changes in performance at sea
level remain elusive. Intermittent altitnude
training has been shown to increase the hypc)xic
ventilatory response in a group of sedent:ary
subjects, whereas an equivalent training pro-
gramme at sea level had no effect.'4 9 Ac ute
exposure to altitude in the native lowlanLder
may potentiate the hypoxic ventilatory re-
sponse because of an increased periph(eral
chemoreceptor sensitivity, which would sut)se-
quently increase the work performed by the
respiratory muscles. This has not been quainti-
fied in the elite athlete but may be implicate(d in
the performance decrements shortly atfter
return to sea level. Plasma volume has bteen
shown to decrease by 25% during chrc)mnc
exposure to hypobaric hypoxia" and may ttake
as long as two months to normalise.9' After
return to sea level, this may remain depres;sed
for six days,96 which may also negatively afl[ect
performance. Altitude training may also in-
volve considerable travelling time, and the
187
negative impact of jet lag on exercise perform-
ance cannot be ignored.97
Measurement of the altitude effect
independent of training
Figure 2 shows that, since 1956, only 27 (30%)
of the 91 hypoxic training studies reviewed
have incorporated a normoxically trained con-
determine whether the physiological changes
that occur after a bout of altitude training can
be attributed to an improvement in physical
conditioning or to the additive effects of
hypoxia itself.
To our knowledge, the altitude training
studies conducted by Asano et al,5" Terrados et
al,5' 52 and Levine et al' would appear to be the
only investigations employing a control group
that have reported statistically significant im-
provements in aerobic performance after re-
turn to normoxia. Asano et al" studied ten elite
middle to long distance male runners, who
trained for a ten week period at the same rela-
tive exercise intensity at either sea level or a
simulated altitude of 4000 m. After training,
there were no improvements in Vo2MAX at sea
level, yet 10 km personal best running times
improved by about 6% (P<0.05). Using a one
legged training model, Terrados et alr" 52 attrib-
uted the potentiating effects of intermittent
hypobaric training to increases in citrate
synthase activity and myoglobin content. The
findings of Levine et al5' have already been
described in this review.
Whilst previous investigations have dealt pri-
marily with aerobic responses to altitude train-
ing, there is some evidence to suggest that
anaerobic performance is improved on return
to sea level.' 98 9 Mizuno et at14 showed that
exercise time to exhaustion after altitude train-
ing improved by 17% (P<0.05) when com-
pared with pre-altitude values, which they
attributed to a 6% increase (P<0.05) in muscle
buffer capacity. However, the validity of these
findings is questionable because of the lack of a
normoxically trained control group. A well
controlled investigation by Martino et al,9"
which incorporated a performance matched
control group based at sea level, investigated
the effects of three weeks of altitude training at
2800 m on anaerobic measures of swimming
performance. Sea level sprint performance
time over 100 m was 2.4 seconds quicker in the
altitude trained group than the control group
(P<0.05). The largest improvements in the
altitude trained group were noted in an upper
body Wingate test. Peak power output in-
creased by 27.9 W more than the control group
(P<0.05). In a recent investigation, Nummela
et al99 showed that ten days of living high
(-2200 m) and training low (sea level) resulted
in greater improvements in 400 m running
time (P<0.05) and running velocity at a fixed
concentration of blood lactate (P<0.05) when
compared with an equivalent programme of
sea level training.
However, the vast majority of altitude train-
ing studies have not identified performance
improvements at sea level. Whilst a decrease in
absolute training intensity may be implicated,'"
188
a decrease in muscle perfusion may also play a
contributory role; oxygen transport, deter-
mined as a product of blood flow and arterial
oxygen concentration is regulated during
changes in Pao,. Reductions in blood flow dur-
ing the inhalation of a hyperoxic gas mixture
regulates oxygen delivery to the working
muscles, such that total oxygen delivery is
similar to that observed in normoxia'°°. Auto-
regulation of this mechanism has been investi-
gated at altitude and after return to sea
level."'0 102 Whilst chronic exposure to hypo-
baric hypoxia increased arterial oxygen content
as the result of an increase in Hb concentra-
tion, sympathetically mediated arterial vaso-
constriction and a reduction in total cardiac
output caused a reduction in blood flow, thus
preventing an increase in oxygen transport.'0'
This decrease in muscle perfusion has been
shown to persist after return to sea level. Using
"'Xe, blood flow to the vastus lateralis was
shown to decrease by up to 39% (P<0.001)
during submaximal exercise after a three
month expedition to 8398 m.'0'
Favier et alr suggested that the negative
findings reported in the literature could, in
part, be attributed to the fact that subjects were
not fully acclimatised to hypobaric hypoxia. In
a unique experiment they used three groups of
sedentary high altitude residents, who trained
for 30 minutes a day at a constant work rate on
a bicycle ergometer, during a six week period.
Group 1 trained at a Po, that was equivalent to
an interpolated altitude of 3345 m at 70% of
Vo2mAx determined in hypoxia. The remaining
two groups trained under normoxic conditions
at either the same relative work rate (70% of
the normoxic VO2MAX) or the same absolute
work rate (70% of the hypoxic VO2mAx) as the
hypoxically trained group. An incremental test
to exhaustion was performed by all groups in
normoxia and hypoxia immediately before and
after training in an attempt to ascertain the
physiological responses to submaximal and
maximal exercise. The authors showed that
VO2MAX values improved similarly in all groups.
However, they suggested that a lower reduction
in base excess and bicarbonate stores observed
in the hypoxically trained group could only
potentially benefit anaerobic metabolism and,
although time to exhaustion was not measured,
facilitate exercise performance.
Hypoxia and immune function
Changes in total leucocyte, granulocyte, mono-
cyte, lymphocyte, natural killer cell, and T cell
count, helper/suppression cell ratio, cell prolif-
eration in response to mitogens, and serum
immunoglobin levels have all been implicated
in some form of immunosuppression, which
may subsequently cause underperformance in
the athlete at sea level.'0' The additive stress of
a reduction in the inspiratory Po0, in conjunc-
tion with the extensive training loads employed
by athletes at altitude, may explain why some
investigators have reported physiological evi-
dence for a less favourable modulation of
immune function in vivo during acute and
chronic exposure to hypobaric hypoxia.6' 10-106
Bailey, Davies
Human studies have shown that chronic expo-
sure to hypobaric hypoxia results in a suppres-
sion of cell mediated immunity, whereas B cell
function remains unimpaired."6 Animal studies
have further shown that murine host defences
against bacterial pathogens are also impaired in
hypoxia. The contributory immunomodula-
tory role of endogenous glucocorticoids and
neuropeptides, which are increased at altitude,
may contribute to the observed alterations in
immune competence. In an experiment that
employed elite distance runners and matched
controls, we showed that plasma glutamine
concentrations decreased significantly in com-
parison with pre-altitude values after 20 days of
endurance training at an altitude of 1640 m
above sea level (Po, = 135 mm Hg) (D M
Bailey et al, unpublished work). A reduction in
glutamine concentration has been identified in
"overtrained" athletes and may be a contribu-
tory factor leading to immunosuppression and
underperformance.'0' It is difficult to comment
on the physiological mechanisms responsible
for these changes, but there is evidence that
suggests that chronically elevated levels of
circulating catecholamine levels decrease the
rate of glutamine transport out of muscle incu-
bated in vitro (Parry-Billings M, unpublished
data). In addition to this, Wagenmakers'0' has
proposed an alternative mechanism, again
related to elevated catecholamine levels ob-
served at altitude." He suggested that hypoxia
induced glycogen depletion would result in a
reduction in the availability of tricarboxylic
acid cycle intermediates, in particular
2-oxoglutarate. This is required for the activa-
tion of the branched chain amino acid
aminotransferase reaction, which ultimately
produces glutamine. The implications of the
immunosupressive influence of hypobaric hy-
poxia for endurance performance warrants fur-
ther investigation in order to elucidate potential
mechanisms that may modulate performance
after return to sea level.
Reactive oxygen species at altitude
There is a limited body of evidence suggesting
that oxidative injury mediated by free radicals
is increased at altitude.'09"' Simon-Schnass'09
identified significant increases in indirect indi-
ces of free radical mediated lipid peroxidation
at altitude, which included increased pentane
excretion and thiobarbituric acid reactive sub-
stances, decreased erythrocyte filterability, and
increased leucocyte and granulocyte counts.
Daily supplementation with an antioxidant
such as tocopherol (vitamin E) equivalent to
300-400 mg has been shown to improve
endurance performance, by theoretically limit-
ing tissue damage.'09 "O An accelerated produc-
tion of the highly toxic hydroxyl radical may
occur as a consequence of an increased
production of free iron derived from altitude
induced and training induced destruction of
red blood cells."' Thus it would appear that
hypobaric hypoxia significantly increases oxi-
dative stress, which has been shown to
negatively influence energy metabolism and
membrane integrity.
Altitude training for endurance performance at sea level
Summary and future research
Physiological acclimatisation to a chronically
reduced Ppo, is a prerequisite to achieve
optimal physical performance in environmen-
tal hypoxia. However, scientific evidence to
support the claim that either continuous or
intermittent hypoxic training will enhance sea
level performance remains at present equivo-
cal. Future research should focus on
methodological technicalities that optimise the
balance between the favourable and less
favourable responses to hypoxia and potential
mediators of performance after return to sea
level. Preliminary evidence showing that the
additive stress of hypobaric hypoxia may
provoke an adverse immune response and fur-
ther potentiate free radical mediated oxidative
injury has important implications which, if
confirmed by scientific rigor, would present a
threat to both the fitness and health of the elite
competitor.
Our research was supported by the British Olympic Association
and the British Athletics Federation. We would also like to
acknowledge Mr N Papps of Ordnance Survey, UK, and Mr S
Greenberg for their keen assistance in collecting data contained
in fig 1.
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