Team Physician's Corner
POSITIVE OUTCOMES OF SPORTS PARTICIPATION
Micheal B. Minix, Sr., M.D. Research
“The nature of parental or adult involvement can also influence the degree to which participation in organized sports is a positive experience for preadolescents. This updates a previous policy statement on athletics for preadolescents and incorporates guidelines for sports participation for preschool children. Recommendations are offered on how pediatricians can help determine a child’s readiness to participate, how risks can be minimized, and how child-oriented goals can be maximized.”
“To optimize the safety and benefits of organized sports for children and preadolescents and to preserve this valuable opportunity for young people to increase their physical activity levels, the American Academy of Pediatrics recommends the following:
1. Organized sports programs for preadolescents should complement, not replace, the regular physical activity that is a part of free play, child-organized games, recreational sports, and physical education programs in the schools. Regular physical activity should be encouraged for all children whether they participate in organized sports or not.
2. Pediatricians are encouraged to help assess developmental readiness and medical suitability for children and preadolescents to participate in organized sports and assist in matching a child’s physical, social, and cognitive maturity with appropriate sports activities.
3. Pediatricians can take an active role in youth sports organizations by educating coaches about developmental and safety issues, monitoring the health and safety of children involved in organized sports, and advising committees on rules and safety.
4. Pediatricians are encouraged to take an active role in identifying and preserving goals of sports that best serve young athletes.
5. Additional research and resources are needed to:
a. determine the optimal time for children to begin participating in organized sports;
b. identify safe and effective training strategies for growing and developing athletes;
c. educate youth sports coaches about unique needs and characteristics of young athletes;
d. develop effective injury prevention strategies.”
[Committee on Sports Medicine and Fitness, 2000-2001, Reginald L. Washington, MD, Chairperson, PEDIATRICS Vol. 107 No. 6 June 2001, pp. 1459-1462, AMERICAN ACADEMY OF PEDIATRICS: Organized Sports for Children and Preadolescents, Committee on Sports Medicine and Fitness and Committee on School Health]
Balance, moderation, time management, appropriate parental support and proper Child Custodial Protection and Coaching Supervision and Athlete Safety First are necessary for Athlete-Centered Sports and Athlete Rights.
The negative outcomes of sports are the result of poor coaching, parental pressures and preventable, non-accidental sports injuries. [The Negative Effects of Youth Sports, Livestrong.com, Steve Silverman]
“Mahoney suggested that participation in voluntary, school-based, extracurricular activities increases school participation and achievement because it facilitates:
(a) the acquisition of interpersonal skills and positive social norms
(b) membership in pro-social peer groups.
(c) stronger emotional and social connections to one’s school.
In turn, these assets should increase mental health, school engagement, school achievement, and long-term educational outcomes and should decrease participation in problem behaviors, provided that problem behaviors are not endorsed by the peer cultures that emerge in these activities.” [Mahoney et al]
“Participation in extracurricular and service learning activities has also been linked to increases in interpersonal competence, self-concept, high school grade point average (GPA), school engagement, and educational aspirations” [Elder & Conger, 2000; Marsh & Kleitman, 2002; Youniss, McLellan, & Yates, 1999], as well as to higher educational achievement, better job quality, more active participation in the political process and other types of volunteer activities, continued sport engagement, and better mental health during young adulthood [Barber, Eccles, & Stone, 2001; Glancy, Willits, & Farrell, 1986; Marsh, 1992; Youniss, McLellan, Su, & Yates, 1999].
Sports participation has been linked to lower likelihood of school dropout and higher rates of college attendance, particularly for low achieving and blue-collar male athletes (Gould & Weiss, 1987; Marsh & Kleitman, 2003; McNeal, 1995).
These studies provide good evidence that participating in extracurricular activities is associated with both short and long term indicators of positive development including school achievement and educational attainment. Some of these relations hold even after the other obvious predictors of such outcomes are controlled–giving us some confidence that these effects do not just reflect the selection factors that lead to participation in the first place.[Extracurricular activities and adolescent development. Journal of Social Issues, December 22, 2003, Eccles, Jacquelynne S.; Barber, Bonnie L.; Stone, Margaret; Hunt, James]
“How young people spend their time outside of school has consequences for their development.” Organized extracurricular activities, after-school programs, and youth organization have significantly escalated. Research reveals positive outcomes “of participation for academic, educational, social, civic, and physical development”. Combining this with the potential for safety and supervision provided by organized activities while parents are working has increased local, state, and Federal authorities to increase these opportunities.
However, there is concern that these organized activities have become excessive for youth. “Over-scheduling” is thought to result from pressure from adults (parents, coaches, teachers) to achieve and attain long-term educational and career goals.
Others say the increase in these activities and outside pressures contribute to poor youth psychosocial adjustment and to undermine their relationships with parents and the function of the family circle
The study attempted to resolve the question. The result:
“(1) The primary motivations for participation in organized activities are intrinsic (e.g., excitement and enjoyment, to build competencies, and to affiliate with peers and activity leaders). Pressures from adults or educational/career goals are seldom given as reasons for participation;”
“(2) American youth average about 5 hours/week participating in organized activities. At any given time, roughly 40% of young people in the US do not participate in organized activities and those who do typically spend less than 10 hours/week participating. Many alternative leisure activities (e.g., educational activities, playing games, watching television) consume as much or considerably more time. However, a very small subgroup of youth (between 3 and 6 percent) spends 20 or more hours/week participating;”
(3) “Youth who participate demonstrate healthier functioning on such indicators ranging from academic achievement, school completion, post secondary educational attainment, psychological adjustment, and lowered rates of smoking and drug use, to the quantity and quality of interactions with their parents.
(4) Very high levels of involvement in organized activity participation (e.g., 20 or more hours/week), adjustment appeared more positive than, than youth who did not participate.
Participation is associated with positive developmental outcomes for most youth. “The well-being of youth who do not participate in organized activities is reliably less positive compared to youth who do participate.”
[Organized Activity Participation, Positive Youth Development, and the Over-Scheduling Hypothesis, Joseph L. Mahoney, Angel L. Harris, and Jacquelynne S. Eccles, Volume XX, Number IV, Social Policy Report, 2006]
THE HAZARDOUS EFFECTS ON YOUTH FOOTBALL ATHLETES WHEN EXERCISING TO EXHAUSTION IN DANGEROUS HEAT AND OZONE
Micheal B. Minix, Sr., M.D. Research
We “old timers” were acclimated to hot weather 50 years ago. When kids, we played outside all day, because we had nothing else but sports activities to occupy our time. We had no computers, video games or central air conditioning. Air pollution was non-existent. Today, in contrast, football is a much different sport, because 4 conditions have changed and one unfortunately remains the same for an estimated 20% of coaches.
Now there are drastically different non-acclimated football athletes, drastically different weather conditions that include global warming and air pollution.
In addition, youth athlete football participation is increasing dramatic and the football community at times appears dysfunctional when turning a blind eye to youth sports safety.
Because of my football experience, medical education, and research, I caution tossing in the mix a win-at-all-cost coach, a coercive disciple, who overlooks and ignores hazardous environmental conditions during football practice and play.
Youth football athletes are not acclimated to hot weather nowadays. They only go outside to practice football when the season begins. The news is that they potentially practice outside in dangerous heat combined with air pollution. Often the detrimental air pollutant is Ozone.
OZONE TOXICITY is a well known toxic condition affecting both human and plant life. “New statistics from the World Health Organization show that in the United States, air pollution annually kills nearly twice as many people as do traffic accidents and that deaths from air pollution equal deaths from breast cancer and prostate cancer combined,” said Tiffany Schauer, executive director of Our Children’s Earth Foundation. The 2008 Beijing Olympic Smog has been systematically researched and confirmed as an athlete hazard.
Ozone (O3) is a tri-atomic molecule. It has three oxygen atoms. Ozone on ground level is an air pollutant with harmful effects on human lungs and the entire respiratory system. On the other hand, the ozone layer in the upper atmosphere is beneficial, acting as a filter and preventing potentially damaging ultraviolet light from reaching the Earth’s surface.
Ground level Ozone peaks in the afternoon after sunlight cooks air-born nitrogen oxides, volatile organic compounds and sulphur dioxide, after air pollution has been emitted during the day.
Ozone is a more powerful oxidizing agent than O2. The Ozone oxidation of human tissue cells in the lungs and the entire respiratory system, when bad air is inhaled by football athletes, proceeds rapidly with increasing dangerously hot weather. Ozone and heat act synergistically causing a greater effect on body tissues when combined together in the inhalation gas mixture that aerates the lungs. The two appear to have a linear relationship.
Ozone can irritate the respiratory system causing coughing and tightness in the chest. Hallmark signs are when football athletes retch and have difficulty breathing. Breaths might be more rapid and shallow,. Symptoms may last hours after exposure.
Pre-existing Asthma is aggravated by Ozone. Asthmatics are more greatly affected by the irritant and high levels result in a greater number of asthma attacks and hospitalizations. Ozone also makes asthmatics more sensitive to allergens that cause asthma attacks and can aggravate chronic lung diseases like bronchitis and infections.
The inflammation and damage to the epithelial cells lining the entire respiratory system and lungs can be silent and rapid for certain groups of football athletes. Often there is no warning.
Ozone damage can occur without any noticeable signs. Football athletes initially might not manifest symptoms, but as Ozone continues to cause lung damage, the athlete might become symptomatic and suddenly collapse.
Pulmonary damage can be irreversible in some football athletes. ARDS (Acute Respiratory Distress Syndrome) is the most serious result. ARDS results in a fibroproliferative reaction that lines and blocks off the permeable wall of the alveolar sacs. Oxygen cannot be exchanged with circulating pulmonary blood. Sudden catastrophic collapse ensues after oxygen deprivation. Death is almost certain after ARDS begins. Even steroids are ineffective.
Scientists are researching ozone’s long-term effects. Youth football athletes repeatedly exposed to high levels of ozone may sustain lung damage, absent an acute attack. Studies suggest that ozone may also harm resistance to respiratory infections and later in life cause lung cancer.
Every coach must daily check the Air Quality Index and Heat Index on their field of play or practice. Coaches have a duty to protect children who are participating in sports activities. They are transferred the chain of protective custody for our children.
An AQI of 0-50 usually has no abnormal health effects. When there is an AQI of 51-100, football athletes with respiratory disease and asthma should not practice football outside. During an AQI 101-150 in addition to asthmatics, an athlete in the sensitive group, should not practice football outside.
The problem with this category is that members of the sensitive group might catastrophically only become known following collapse. During dangerous heat, no one should practice football outdoors with AQI greater than 100.
Youth football athletes should move indoors to practice and play in any of the following categories: AQI 101 – 150 “Unhealthy for Sensative Groups”, AQI of 151 – 200 is “Unhealthy". AQI of 201 – 300 is "Very Unhealthy” and AQI greater than 300 is ”Hazardous"*.
Another serious precaution has been discovered but not reported. Activity diesel school buses may arrive near the end of football practice. If they park and idle near practice fields, while football athletes are running gassers or wind sprints at the end of practice, they can create “hot spots” of Ozone in already hazardous heat and Ozone environment. This may push athletes’ Ozone Toxicity over the edge. Beware.
Exercise to exhaustion in dangerous heat and ozone is a formula for youth football athlete death. Body organs bake and oxidize. Children die. Often Ozone Toxicity is accompanied by Exertional Heat Stroke.
Micheal B. Minix, Sr., M.D. Research
The Kentucky Traumatic Brain Injury Prevalence Study January, 2004 showed that sports and recreational activities were the second leading cause of Traumatic Brain Injuries (TBI) in Kentucky. Sports and recreational represents 17.1% of TBI. Automobile accidents were first at 34%. These two were by a considerable margin the leader categories.
American football athletes and coaches often suffer with mental illness and depression from concussions. Multiple head injuries have been shown to result in severe mental illness to football players later in their life. A traumatic brain injury is characterized by loss of consciousness, confusion, amnesia for the events, and other neurological signs. Concussion often results later with loss of mental functioning, memory, migraine, seizures, dizziness, and depression.
Charlie Pell, a Bear Bryant disciple, and an assistant to Charlie Bradshaw at University of Kentucky from 1965-1969 suffered with severe depression. Pell made a public service documentary about his depression for the state of Alabama. His documentary was a very noble achievement and an excellent source of public information.
Bear Bryant said he cried often when head coach at Kentucky. He would often stop and vomit on the way to football practice and games. “I’ll tell you I’ve cried, literally cried like a baby” over some minimal matters.
Bryant was a textbook example of depression. He felt hopelessness and insecurity. Bryant manifested the depressive symptoms of inappropriate crying, empty feelings, loss of confidence and loss of temper. He was irritable, felt miserable, had difficulty sleeping and awakened too early.
An investigation has been conducted concerning the association between prior head injury and the likelihood of being diagnosed with clinical depression among retired professional football players. Depression is the most cited psychological disturbance after traumatic brain injury, with prevalence rates from 6% in cases of mild traumatic brain injury to 77% in more severe TBI within the first year after injury. Retired players reporting three or more previous concussions (24.4%) were three times more likely to be diagnosed with depression; those with a history of one or two previous concussions (36.3%) were 1.5 times more likely to be diagnosed with depression.
“In 2001 Kevin Guskiewicz, research director of the Center for the Study of Retired Athletes at the University of North Carolina at Chapel Hill was surprised by the depression statistics. Athletes with no concussions had a lifetime depression diagnosis rate of 6.6 %. That is about the same as the general male population. Once they suffered three or more traumas, however, the rate skyrocketed to 20.2 %. The depressions, can interact with other health problems to destroy the former athletes’ lives. The depressions have a snowball effect. The football player is retired from football, overweight, has musculoskeletal problems like sore knees, ankles, hips, not exercising. and life begins to go downhill.”.
Concussions can trigger a chemical chain reaction in brain neurons that that can cause athlete disorientation, unconsciousness, or death. TBI can also impair learning over a period of years. Barret Robbins, Oakland Raiders Pro Bowl center, suffered from severe depression. “The demons running loose inside Barret Robbins’ head put the football player in a San Diego hospital on Super Bowl Sunday”. The physical power of his 6-foot-3, 320-pound body was no match for the illness.
Athletes can be devastated by emotional and physical changes that come with depression. Worse is the athletes’ unwillingness to deal with their condition. The tough-man football environment makes them ashamed of their supposed “weakness,” Physical side effects from medication and the depression are the most difficult opponents they will ever confront.
”As athletes, we are taught to be tough,” said former NHL all-star Pat LaFontaine, who has battled depression. “You get up and shake it off. But you can’t do that with depression”. Former U.S. Olympic diver Wendy Williams once collapsed in front of her refrigerator, overwhelmed by something as simple as deciding what to eat. She quit getting into her car for fear she would drive off a cliff to escape her misery. “For me, the harder I tried, the worse it got.” Spiraling into shadows so dark she thought she’d never get out.
Harry Carson, middle linebacker with the New York Giants was a renowned defensive football player, intelligent, athletic and forceful, selected for the Pro Bowl. He was known for aggression. After a collision a dazed, Carson got up and walked back into the Giants’ huddle. As he stood holding his teammates’ hands, everything went black. He didn’t faint or stop playing. He was unable to figure out his coach’s signals from the sidelines. He couldn’t call the next play, as the middle linebacker is expected.
Blackouts like these were becoming familiar sensations for Carson. Over 13 seasons, he estimates he received between 15 and 18 concussions. Toward the end of his career Carson began to exhibit the cumulative effects of all these hits. He developed post concussion syndrome.
Carson developed headaches and muscle twitches. He grew sensitive to bright lights and loud noises, making it difficult for him to sit in a busy restaurant or do a television interview. He’d lose track of time. Athletes like Carson were not studied by scientists until recently. Because of the numerous football fatalities each year in the 1960s, particularly at the high school level, researchers were much more concerned with on-field catastrophes.
“When someone dies, that catches everyone’s attention,” says neurosurgeon Robert Cantu, medical director of the National Center for Catastrophic Sports Injury Research. “It’s not surprising that fatalities in football have been tracked since 1931.”
“Thanks to better protective equipment and safer coaching techniques, football deaths have now dropped to single digits each year. The decline has allowed scientists to focus on more subtle traumas, and concussions are chief among them. Neurosurgeons have shown that even a minor ding can trigger a neurological cascade that can eventually cause cognitive dysfunction and mental illness. Among retired football players who have sustained three or more concussions, 20 percent have been diagnosed with clinical depression—more than three times the rate of players who never got a concussion.”
Half of those players are taking antidepressant medications. Most report that the condition impedes their normal daily activities, such as shopping for groceries and going to work. At the UCLA Brain Injury Research Center, neuropsychologist David Hovda has studied the cascade of these injuries. An injured athlete may be oblivious to the neurochemical cascade inside his brain. “You can see a broken arm,” says Carson. “You can see a torn ligament in the knee. But with a concussion, you don’t see it.” The effects show up in statistical research.
Many other sports other than American football have frequent concussions. Soccer, hockey and baseball are examples. Matser and Lezak compared the results of swimmers and runners and found the soccer players were three to four times more likely to show deficits in memory and planning skills. The more concussions players suffered, the lower their scores on three of the 16 tests. Lezak is unsurprised. “I know what happens when you bat on the brain,” she says. “Given what we know about boxing, it would have been surprising if we hadn’t found anything. In soccer, people are punishing themselves in much the same way boxers do.”
The athletic community has developed a heightened awareness concerning traumatic brain injury and concussion. Scientists are researching concussion pathology. Manufacturers are developing better protective helmets. Taking the head out of football during blocking and tackling is an extremely important technique that should be instructed and enforced.
Sports 911 Emergency Action Plan
Micheal B. Minix, Sr., M.D. Research
BOY SCOUT MOTTO: BE PREPARED
Reference: National Cheer Safety Foundation
HOW HOT IS HOT ENOUGH FOR HEAT STROKE
December 7, 2009 by Micheal B. Minix, Sr., M.D. Research
How hot is hot enough to cause a heat stroke is variable because Primary and Secondary Predisposing Risk Factors contribute to Death from heat illness and abnormal body heat balance or abnormal thermoregulation.
There are reports of death from heat illness with temperatures in the 70's, because of Primary and Secondary Predisposing Factors often come into play.
Core Body Temperature above 104° alone from dehydration from insufficient water consumption might not be the sole cause of heat illness. An athlete patient might have one of the following associated with body heat imbalance and lethal body temperature while practicing, playing or exercising in the heat. Water consumption errors do not always account for all heat illness deaths.
PREDISPOSING RISK FACTORS AND HEAT ILLNESS
I. PRIMARY RISK FACTORS FOR HEAT STROKE AFFECT THE AIRWAY, BREATHING AND CIRCULATION/CARDIOVASCULAR SYSTEMS DIRECTLY.
1. Inadequate Oxygen and/ or Inadequate Airway
2. Breathing Difficulty. Can’t Breathe on their own.
3. Circulation Compromise and Cardiovascular Pathology
Athletes can have a Heat Stroke at 70° Fahrenheit if other Risk Factors are in effect, most notably the Primary Risk Factors. A dangerous Air Quality Index (AQI) is a Primary Risk Factor. It directly affects the Airway, Breathing, Circulatory and Cardiovascular systems, the ABC’s of Resuscitation. Medications and infections are Secondary Risk Factors. They are less fast fatal Risk Factors.
The ABC’s of Resuscitation are a mnemonic used in the care of the unconscious or unresponsive patient. It is used as a reminder of the priorities for assessment and treatment of patients in many acute medical and trauma situations. Airway, breathing, and circulation are vital for life, and each is required, in that order, for the next to be effective. The Heat Stroke Patient must have the ABC’s attended and stabilized first in that order:
SECONDARY RISK FACTORS
Heat Illness Prevention
II. Pathophysiology Predisposing conditions alter heat balance
William O. Roberts, MD, sports medicine MinnHealth in White Bear Lake, Minn Czerkawski (1996) Your Patient Fitness 10(4): 13-20
Sandor (1997) Physician SportsMed, 25(6):35-40
Barrow (1998) Am Fam Physician 58(3):749
Hett (1998) Postgrad Med 103(6):107
Wexler (2002) Am Fam Physician 65(11):2307
Promoting athlete’s safety is essential. Youth athlete injuries and heat illness have significantly increased during the last decade. Safe sports supervision and environments are imperative.
Coaching athletes in the 21st Century is unlike coaching them in the 20th Century, because today’s youth are different. First and foremost they are not as acclimatized to outside heat as athletes were 50 years ago, when central air conditioning wasn’t standard equipment, and indoor games and computers were non-existent. Athletes played outside many hours each day.
This fall before schools begin, youth athletes will begin conditioning and practicing for their fall schedules. Intense conditioning and practice will require replacement of water and salt because of loss from sweating.
The signs and symptoms are headache, dizziness fainting, weight loss, increased body temperature, thirst, muscle cramps, nausea and maybe seizures and unconsciousness.
Reference: American Academy of Pediatrics Committee on Sports Medicine, heat related illnesses are all preventable. (Sports Medicine: health Care for Young Athletes, American Academy of Pediatrics, 1991.)
"1. Each athlete should have a physical examination with a medical history when first entering a program and an annual health history update. History of previous heat illness and type of training activities before organized practice begins should be included. State High School Associations recommendations should be followed.
2. It is clear that top physical performance can only be achieved by an athlete who is in top physical condition. Lack of physical fitness impairs the performance of an athlete who participates in high temperatures. Coaches should know the physical condition of their athletes and set practice schedules accordingly.
3. Along with physical conditioning the factor of acclimatization to heat is important. Acclimatization is the process of becoming adjusted to heat and it is essential to provide for gradual acclimatization to hot weather. It is necessary for an athlete to exercise in the heat if he/she is to become acclimatized to it. It is suggested that a graduated physical conditioning program be used and that 80% acclimatization can be expected to occur after the first 7-10 days. Final stages of acclimatization to heat are marked by increased sweating and reduced salt concentration in the sweat.
4. The old idea that water should be withheld from athletes during workouts has no scientific foundation. The most important safeguard to the health of the athlete is the replacement of water. Water must be on the field and readily available to the athletes at all times. It is recommended that a minimum of 10 minute water breaks be scheduled for every half hour of heavy exercise in the heat. Athletes should rest in a shaded area during a break. Water should be available in unlimited quantities. Check and be sure athletes are drinking the water. Cold water is preferable. Drinking ample water before practice or games has also been found to aid performance in the heat.
5. Salt should be replaced daily. Modest salting of foods after practice or games will accomplish this purpose. Salt tablets are not recommended. Attention must be directed to replacing water - fluid replacement is essential.
6. Know both the temperature and humidity. The greater the humidity the more difficult it is for the body to cool itself. Test the air prior to practice or game using a wet bulb, globe, temperature index (WBGT index) which is based on the combined effects of air temperature, relative humidity, radiant heat and air movement. The following precautions are recommended when using the WBGT Index: (ACSM's Guidelines for the Team Physician, 1991).
There is also a weather guide for activities that last 30 minutes or more (Fox and Mathews, 1981) which involves knowing the relative humidity and air temperature:
RH= Relative Humidity
One other method of measuring the relative humidity is the use of a sling psychrometer, which measures wet bulb temperature. The wet bulb temperature should be measured prior to practice and the intensity and duration of practice adjusted accordingly. Recommendations are as follows:
7. Cooling by evaporation is proportional to the area of the skin exposed. In extremely hot and humid weather reduce the amount of clothing covering the body as much as possible. Never use rubberized clothing.
8. Athletes should weigh each day before and after practice and weight charts checked. Generally a 3 percent weight loss through sweating is safe and over a 3 percent weight loss is in the danger zone. Over a 3 percent weight loss the athlete should not be allowed to practice in hot and humid conditions. Observe the athletes closely under all conditions.
9. Observe athletes carefully for signs of trouble, particularly athletes who lose much weight and the eager athlete who constantly competes at his/her capacity. Some trouble signs are nausea, incoherence, fatigue, weakness, vomiting, cramps, weak rapid pulse, visual disturbance and unsteadiness.
10. Teams that encounter hot weather during the season through travel or following an unseasonably cool period, should be physically fit but will not be environmental fit. Coaches in this situation should follow the above recommendations and substitute more frequently during games.
11. Know what to do in case of emergency and have your emergency plans written with copies to all your staff. Be familiar with immediate first aid practice and prearranged procedures for obtaining medical care, including ambulance service. Heat Stroke: This is a medical emergency - delay could be fatal. Immediately cool body while waiting for transfer to a hospital. Remove clothing and use cool water on body. An increasing number of medical personnel are now using a treatment for heat illness that involves applying either alcohol or cool water to the victim's skin and vigorously fanning the body. The fanning causes evaporation and cooling. (Source - the First Aider, September 1997) Heat Exhaustion: Obtain medical care at once. Cool body as you would for heat stroke while waiting for transfer to hospital. Give fluids if athlete is able to swallow and is conscious.
SUMMARY: The main problem associated with exercising in the hot weather is water loss through sweating. Water loss is best replaced by allowing the athlete unrestricted access to water. Water breaks two or three times every hour are better than one break an hour. The small amount of salt loss in sweat is adequately replaced by salting foods at meals. Talk to your medical personnel concerning emergency treatment plans.”