Intermittent hypoxic training (IHT), also known as intermittent hypoxic therapy, is a non-invasive, drug-free technique aimed at improving human performance and well-being by way of adaptation to reduced oxygen.
An IHT session consists of an interval of several minutes breathing hypoxic (low oxygen) air, alternated with intervals breathing ambient or hyperoxic air. This procedure is repeated over a 45- to 90-minute session per day, with a full treatment course taking three to four weeks.
Standard practice is for the patient to remain stationary while breathing hypoxic air via a hand-held mask. The therapy is delivered using a hypoxicator during the day time, allowing the dosage to be monitored. Biofeedback can be delivered using a pulse oximeter.
The phenomenon of IHT is that it delivers a non-damaging training stimulus that naturally triggers a cascade of beneficial adaptive responses without adverse effects. The response is almost instant and is evident at various levels, from systemic down to cellular. Treatment dosage of IHT can be measured and expressed using the hypoxic training index.
It is important to differentiate between physiological adaptations to mild hypoxia and reoxygenation episodes (i.e., the IHT protocol) and frequent nocturnal suffocation awakenings produced by sleep apnea, which might result in various pathologies.
When used for performance enhancement in sports settings IHT improves mitochondrial status, leading to improvements in aerobic and anaerobic performance.
IHT can be beneficial for the treatment of a wide range of degenerative diseases, including:
- Chronic heart and lung diseases
- Hypertension
- Asthma and chronic bronchitis
- Liver and pancreatic diseases
- Anxiety and depression
- Iron-deficiency anaemia
- Lack of energy and fatigue
IHT is contra-indicated in case of:
- Acute somatic and viral diseases
- Chronic obstructive pulmonary disease (COPD-II and COPD-III)
- Chronic diseases with symptoms of decompensation or terminal illness
- Individual intolerance of oxygen insufficiency
- Cancer, unless IHT is prescribed by a doctor
- People with epilepsy, pacemakers or heart arrhythmias, unless treatment (including IHT) is under direct medical supervision.
Although there are no reported adverse effects with IHT, basic treatment protocol suggested by the manufacturer must be followed.
Altitude training has become very popular among athletes as a means to further increase exercise performance at sea level or to acclimatize to competition at altitude. Several approaches have evolved during the last few decades, with “live high-train low” and “live low-train high” being the most popular. This review focuses on functional, muscular, and practical aspects derived from extensive research on the “live low-train high” approach. According to this, subjects train in hypoxia but remain under normoxia for the rest of the time. It has been reasoned that exercising in hypoxia could increase the training stimulus.
Is Hypoxia Training good for Muscles and Exercise Performance
Advancing Hypoxic Training in Team Sports: from intermittent hypoxic training to repeated sprint training in hypoxia
Over the past two decades, intermittent hypoxic training (IHT), that is, a method where athletes live at or near sea level but train under hypoxic conditions, has gained unprecedented popularity. By adding the stress of hypoxia during ‘aerobic’ or ‘anaerobic’ interval training, it is believed that IHT would potentiate greater performance improvements compared to similar training at sea level. A thorough analysis of studies including IHT, however, leads to strikingly poor benefits for sea-level performance improvement, compared to the same training method performed in normoxia.
Despite the positive molecular adaptations observed after various IHT modalities, the characteristics of optimal training stimulus in hypoxia are still unclear and their functional translation in terms of whole-body performance enhancement is minimal. To overcome some of the inherent limitations of IHT (lower training stimulus due to hypoxia), recent studies have successfully investigated a new training method based on the repetition of short (<30 s) ‘all-out’ sprints with incomplete recoveries in hypoxia, the so-called repeated sprint training in hypoxia (RSH).
The aims of the present review are therefore threefold: first, to summarise the main mechanisms for interval training and repeated sprint training in normoxia. Second, to critically analyse the results of the studies involving high-intensity exercises performed in hypoxia for sea-level performance enhancement by differentiating IHT and RSH. Third, to discuss the potential mechanisms underpinning the effectiveness of those methods, and their inherent limitations, along with the new research avenues surrounding this topic.The study has been done by Raphaël Faiss, Olivier Girard and Grégoire P Millet is available at: http://bjsm.bmj.com/content/47/Suppl_1/i45.full.html
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On 28 August 2004 the Moroccan Hicham El Guerrouj won the men’s 5,000m Olympic final in a time of 13:14.39. The race had been close: only 10 seconds separated the first seven competitors, and less than one second had divided the medallists. In elite endurance events such as the 5,000m, where seconds can make the difference between success and failure, it is no surprise to learn that athletes and coaches are constantly striving for legitimate advantage over their rivals.
In the early 1990s, Benjamin Levine, a researcher at the University of Texas, seemed to have made such a discovery. By exposing college athletes to low concentrations of oxygen (hypoxia) during rest, and normal conditions (normoxia) during exercise, Levine and his colleagues were able to show that 5,000m times could be improved by an average of 13.4 seconds in elite college athletes. Although this ‘live high, train low’ approach to intermittent hypoxic training (IHT) is now widely used by endurance athletes across the world, a number of problems and controversies still exist with the technique. Here, we look at the issues and provide some practical guidance for those who wish to incorporate this technique into their training programme.
Air pressure: the basics
It is worth spending a few moments considering the movement of oxygen inside the body. Unlike solids and liquids, gases expand in all directions and occupy the space in which they’re contained. This makes units of weight and volume redundant; instead gases are measured in units of pressure. In an enclosed space filled with gas, molecules are continually colliding with each other and the walls that contain them. As more gas molecules are added, the collisions become more frequent and the pressure exerted on the walls of their container increases. This pressure can be expressed in a host of different units. Here, I use two common units: the kilopascal (KPa) and the millimetre of mercury (mmHg).
At sea level the pressure exerted by all the gases in the atmosphere (nitrogen, oxygen, carbon dioxide and a host of rare gases) adds up to 101 KPa (760 mmHg). As 21% of the atmosphere is made up of oxygen, the pressure exerted by oxygen alone (often referred to as the ‘partial pressure of oxygen’) is approx 21 KPa (160 mmHg).
As you climb to altitude, the number of molecules in the atmosphere falls, leading to fewer collisions and a fall in pressure. On the summit of Mt Kilimanjaro (5,895m) the atmospheric pressure is 50 KPa (380 mmHg); on Mt Everest (8,850m) the atmospheric pressure stands even lower at 34 KPa (253 mmHg).
Despite these tremendous changes, the proportion of each gas in the atmosphere remains the same. Therefore, to calculate the partial pressure of oxygen the atmospheric pressure is multiplied by the proportion of oxygen (0.21).
Clearly, the simplest way to expose athletes to hypoxia is to encourage them to live at altitude. Unfortunately, this often proves too costly and time consuming, so two alternatives are available:
*Hypobaric chamber: These devices are constructed from reinforced steel and are usually operated by medical specialists. They work by removing an equal proportion of gases from the chamber, thereby reducing the atmospheric pressure inside. This is exactly what happens during a climb to altitude.
*Hypoxic device: Instead of lowering pressure, these devices remove only oxygen and replace the missing space with nitrogen gas. This maintains a normal atmospheric pressure whilst reducing the partial pressure of oxygen, creating a hypoxic environment at sea level. This arrangement is much simpler to organise than a hypobaric chamber and is the easiest way for sea level athletes to experience hypoxic conditions. Such devices come in all shapes and sizes, from large living quarters to small portable face mask systems.
However, it is not yet clear whether these systems produce the same responses as those seen in Levine’s volunteers.
According to the eminent physiologist John West, ‘The underlying rationale is that sleeping at high altitude increases the red cell concentration of the blood and thus endows some advantage, whereas the actual training should be at sea level where the aerobic machinery can be driven to its maximum.’ Let’s take the two points raised by West in turn.
i. Changes in red cell concentration
After just two hours of breathing 10% oxygen, the first physiological changes can be seen in the circulation. The production of erythropoietin, a hormone synthesised by the kidneys, rapidly increases and immediately sets to work coaxing the bone marrow into releasing large quantities of red blood cells. For the athlete, this is great news as an increase in red cell concentration means a rise in the oxygen-carrying capacity of the blood and a fall in cardiac output (the amount of blood ejected by the heart in a minute), which results in the tissues having a longer period of time to extract oxygen. The end result is something not far from finding the Holy Grail: an increase in the maximum oxygen consumption (VO2 max) and, with it, a rise in the athlete’s maximum work rate.
In addition to this profound change, a number of studies have also pointed towards other adaptations that occur within the muscles themselves. This is hardly surprising as hypoxia triggers the activation of HIF-1? (hypoxic inducible factor -1?), which is responsible for stimulating the production of proteins from a range of different genes.
ii. Training at sea level
In a series of experiments, Levine and his colleagues found that resting and training at altitude (‘live high, train high’) fails to produce improvements in performance. Although training in a hypoxic environment feels considerably harder than at sea level, athletes are unable to reach their maximum work rates or levels of oxygen consumption. This is like driving a car at speed in third gear – although it feels much harder, progress is slow.
When healthy, well acclimatised volunteers ascend to altitude, VO2 max falls prodigiously. This inability to use oxygen at higher altitudes results in a fall in maximum aerobic power of approx 1% for every 100m gained above 1,500m of altitude. Therefore, the end result for any athlete who trains at high altitude for any length of time is a fall in the levels of exercise intensity and a general reduction in their overall level of physical fitness.
The evidence for ‘live high, train low’
With more than 15 years of evidence now available, we still have uncertainty and controversy, as well as areas of agreement in the research. Three preliminary observations are worth making:
i. Quality: Quality research in this area is expensive and time consuming. The best studies have been funded by substantial grants from either the International Olympic Committee or national sports agencies. Much of the work is otherwise poorly financed and this is reflected in the small sample sizes, absence of control groups and insufficient follow-up times that characterise many of these studies. Any conclusions drawn from such work need to be treated with a great deal of caution and are mostly avoided here.
ii. Participation: Most participants in ‘live high, train low’ trials are young, white and male elite athletes. This makes it difficult to apply these results to a wider spectrum of the ‘normal’ population.
iii. Specificity: The majority of work has focused upon the performance of middle distance runners. Although some work has been undertaken on other elite endurance athletes (skiers, swimmers and cyclists), it would be a leap of faith to apply the findings to other endurance events.
How much hypoxia is good?
In order to obtain improvements in red cell concentration, VO2max and athletic performance, Levine’s athletes lived at an altitude of 2,500m (equivalent to 16% oxygen) for up to 20 hours a day while training at sea level, for four weeks. Few studies have come close to emulating such a lengthy period of exposure, but the results from those that have are worth mentioning here. Despite some agreement with Levine’s findings, a number of studies have shown either no improvement or have identified enhancements in performance without a change in red cell concentrations.
Recent research has shown that the HIF-1?protein not only stimulates the formation of red cells but has also been linked with improvements in muscle efficiency. This is characterised by improvements in blood flow, the supply of glucose and the clearance of lactic acid from working muscles. These changes may be of considerable benefit to the Olympic 5,000m finalist and therefore offer a clear advantage over a simple blood transfusion or ‘blood doping’, which often occurs before major sporting events.
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Gains, but for how long?
At present little is known about the nature of any long-term benefits that may be conferred by a ‘live high, train low’ regime. Only a handful of studies have monitored volunteers after the completion of their trial, and those that have were stopped after three weeks. In participants who demonstrated a rise in red cell concentration and VO2 max, it would be reasonable to expect improvements in performance to last for the lifetime of their new red blood cells. This may not be very long, however, because red cells undergo premature destruction over just a few days when they’re no longer needed.
In those athletes who do not increase their red cell production during hypoxic exposure, outcomes are even more unpredictable. In this group, red cells are either produced slowly, with concentrations ‘peaking’ late, or else these subjects simply fail to make any response to the level of hypoxic exposure. The result? Either a lengthy delay in response, or worse, no improvement at all. To further confuse matters, some small improvements in performance are sometimes seen in a few of those who fail to recruit additional red cells.
At present the studies that address this issue are small and conflicting, leaving little for us to go on. However, it is thought that positive changes may be due to subtle improvements in muscle performance triggered by the hypoxic stimulus.
Importantly, this research refers to sea level rather than high-altitude performance. The benefits of altitude training for high altitude events is complex.
Who does not benefit?
The response to hypoxia is complex and varies widely from individual to individual. This was confirmed by a study that examined the 39 athletes who had participated in Levine’s landmark experiment. Among those individuals who had failed to respond to the ‘live high, train low’ regime, the study noted that a much smaller and briefer increase in erythropoietin occurred than in those who responded to hypoxia. These ‘nonresponders’ also failed to show any improvements in red cell production, VO2 max or 5,000m
performance times.
As yet there is no way to distinguish ‘nonresponders’ from ‘responders’ prior to undergoing altitude training. However, it may be possible to distinguish another group who are also unable to respond to hypoxia. Levine’s long-time co-worker, James Stray-Gunderson, identified iron deficiency in up to 40% (20% men and 60% women) of competitive distance runners. Without this essential element, red cells cannot be formed and no amount of erythropoietin will help. Simple blood tests can identify iron deficiency and it can be easily addressed with iron supplements and changes in diet.
Disadvantages of ‘live high, train low’
*Acute mountain sickness (AMS): This is particularly common on arrival at altitudes above 2,500m and is associated with headache, nausea, loss of appetite, fatigue, weakness and sleep disturbance. AMS is also associated with the development of rare conditions such as high altitude pulmonary oedema (HAPE) and high altitude cerebral oedema (HACE), which can be fatal if left untreated. It is therefore vital for athletes and coaches to be aware of such conditions and seek medical advice quickly should problems arise.
*Weight loss and muscle wasting: Weight loss is common with prolonged stays at high altitude. Although the body often targets fat stores in the first days and weeks at altitude, changes in muscle bulk also occur. This is particularly common at higher altitudes, where muscle volume can fall by between 11% and 13%. Lowlanders spending time at altitude also experience changes in the way their muscles obtain glucose and convert it into energy (adenosine triphosphate or ATP). These changes could be responsible for the falls in VO2max that typically occur at altitude.
*Changes in the heart: Hypoxia triggers a rise in blood pressure in those arteries that connect the right ventricle of the heart to the lungs. Although this is usually harmless, prolonged hypoxia can cause the heart to enlarge and increase the oxygen it requires to function effectively. In obstructive sleep apnoea, a common condition characterised by long periods of hypoxia during sleep, an increased risk of high blood pressure and heart disease are both well documented. These findings would suggest that prolonged periods of hypoxia may be dangerous. We do not yet know what period of hypoxia is safe, or who may be at an increased risk of developing these problems.
*Reduced immunity: Hypoxia and intensive exercise are both known to impair the immune system. This may result in an increased risk of developing infections, ranging from common colds and flu, to urinary and respiratory tract infections. This effect may also contribute to the delays often seen in those recovering at altitude from softtissue injuries such as cuts, blisters and burns.
*Risk in pregnancy: Hypoxia can reduce the birth weight of babies born to lowland mothers exposed to high altitude and predispose children to a number of conditions. It is therefore vital to ensure that athletes are not pregnant before undertaking a ‘live high, train low’ regime.
*Dehydration: Hypoxia causes a sudden redistribution of body water and an increase in micturition. This leads to a reduction in plasma volume and an immediate increase in the concentration of cells in the circulation. This should be managed by increasing fluid intake during periods of hypoxia.
*Psychological considerations: Spending up to 20 hours a day in a hypoxic tent can test the motivation and commitment of even those striving for Olympic medals. Suitable distractions and incentives need to be provided and should be incorporated into any regime.
Although ‘live high, train low’ regimes are commonly used by elite endurance athletes in the lead up to major competitions, the evidence to support such methods has a number of limitations. The results of Levine and his colleagues are impressive and clearly suggest that a prolonged period of hypoxia during rest periods contributes to improvements in sea level performance. However, controversies still exist and further confirmation is required. Many experts are not yet convinced that ‘live high, train low’ really works and others are unclear about the pathways that confer the benefits described in this article.
Future research will need not only to support these landmark results, but also ‘fine tune’ the degree and duration of hypoxia that is both safe and effective. Until then athletes following ‘live high, train low’ regimes may be placing themselves at considerable risk without necessarily enjoying the benefits that intermittent hypoxia may provide.
Various Researches on Hypoxic Training
A six-week study demonstrated that sprint interval training in hypoxia upregulated muscle phosphofructokinase activity and the anaerobic threshold more than sprint interval training in normoxia, but still did not enhance endurance exercise performance. I believe this was also probably too short. I’m not saying a performance benefit with simulated hypoxia is certain, but if it’s showing improved adaptations over normoxia after six weeks, it’s not a huge leap to believe it could happen.
However, a different study showed that hypoxic conditions combined with sprint training has the ability to stimulate glycolyitic enzyme ability, which would obviously impart a training adaptation if the effect were high enough.
Sprint training at hypoxia equivalent to 2,400m (five sets of three-minute work intervals) showed trends towards improving some areas. Rating of perceived exertion was higher and changes in bicarbonate levels and EPO trended towards possible improvement over normoxic conditions, but changes in 20m sprint time trended lower.
And yet another interval training study, this time in cyclists, found no differences with hypoxic training, either by performance or measurement of monocarboxylate lactate transporter expression.
In addition, fat oxidation was shown in one study to be slightly diminished (which can be a good thing, if we’re looking for endurance and increased substrate efficiency), and had no additive effect on maximal measures of oxygen uptake (VO2peak) or time trial performance (measured under normoxia).
Obviously, the results of acute hypoxic exercise are vastly different than what we see with long-term hypoxic living conditions, as we’d have with the United States Olympic teams, and even those studies have been all over the map with results. Still, with studies, the modality isn’t the sole determinant of success.
An Important Study on Hypoxic Training by Japan Institute of Sports Sciences
The study that meets most of my criteria was performed at the Japan Institute of Sports Sciences. This study used a hypoxic room versus a normoxic room, and had subjects perform eight weeks of resistance training on nonconsecutive days for sixteen sessions in total.
The hypoxic group was exposed to hypoxic conditions from ten minutes before and thirty minutes after the exercise session (vastly different than other protocols). (To the d-bags who wear hypoxic masks to the gym and take them off between sets to talk: you’re doing it wrong.) To investigate acute responses, the subjects were exposed to these conditions from thirty minutes prior to sixty minutes after, on the first and last days.
The resistance exercises consisted of two consecutive exercises (free weight bench press and bilateral leg press using weight stack machine), each with ten repetitions for five sets at 70% of the subjects’ one repetition maximum (1RM) with a ninety second rest.
Strength and size gains were equal for both groups. During the training, levels of plasma oxygen were lower in the hypoxic group (obviously, as they were breathing less oxygen when the tests were taken) but growth hormone levels were significantly higher. The capillary-to-fiber ratio increased more in the oxygen-deprived lifters and vascular endothelial growth factor (VEGF) levels were also higher. Meaning, the hypoxic group was producing more blood cells and better able to restore oxygen supply to tissues when blood circulation wasn’t high enough for the body’s demand.
Therefore, it’s not surprising that local muscular endurance was increased more in the hypoxic group as compared to the normoxic one. It also provides insight into another study that suggested a health benefit from regular short-term hypoxic training, namely the reduction of arterial stiffness and prevention of arteriosclerosis compared to training performed at a similar exercise intensity (under regular, non-hypoxic, conditions).
Recent meta-analysis indicates that high-intensity, short-term, and intermittent training is likely the most beneficial way to benefit from hypoxic training.
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