Context: The National Athletic Trainers' Association and the American College of Sports Medicine have recommended removing American football uniforms from athletes with exertional heat stroke before cold-water immersion (CWI) based on the assumption that the uniform impedes rectal temperature (Trec) cooling. Few experimental data exist to verify or disprove this assumption and the recommendations. Objectives: To compare CWI durations, Trec cooling rates, thermal sensation, intensity of environmental symptoms, and onset of shivering when hyperthermic participants wore football uniforms during CWI or removed the uniforms immediately before CWI. Design: Crossover study. Setting: Laboratory. Patients or Other Participants: Eighteen hydrated, physically active men (age = 22 ± 2 years, height = 182.5 ± 6.1 cm, mass = 85.4 ± 13.4 kg, body fat = 11% ± 5%, body surface area = 2.1 ± 0.2 m2) volunteered. Intervention(s): On 2 days, participants exercised in the heat (approximately 40°C, approximately 40% relative humidity) while wearing a full American football uniform (shoes; crew socks; undergarments; shorts; game pants; undershirt; shoulder pads; jersey; helmet; and padding over the thighs, knees, hips, and tailbone [PADS]) until Trec reached 39.5°C. Next, participants immersed themselves in water that was approximately 10°C while wearing either undergarments, shorts, and crew socks (NOpads) or PADS without shoes until Trec reached 38°C. Main Outcome Measure(s): The CWI duration (minutes) and Trec cooling rates (°C/min). Results: Participants had similar exercise times (NOpads = 40.8 ± 4.9 minutes, PADS = 43.2 ± 4.1 minutes; t17 = 2.0, P = .10), hypohydration levels (NOpads = 1.5% ± 0.3%, PADS = 1.6% ± 0.4%; t17 = 1.3, P = .22), and thermal-sensation ratings (NOpads = 7.2 ± 0.3, PADS = 7.1 ± 0.5; P > .05) before CWI. The CWI duration (median [interquartile range]; NOpads = 6.0 [5.4] minutes, PADS = 7.3 [9.8] minutes; z = 2.3, P = .01) and Trec cooling rates (NOpads = 0.28°C/min ± 0.14°C/min, PADS = 0.21°C/min ± 0.11°C/min; t17 = 2.2, P = .02) differed between uniform conditions. Conclusions: Whereas participants cooled faster in NOpads, we still considered the PADS cooling rate to be acceptable (ie, >0.16°C/min). Therefore, if clinicians experience difficulty removing PADS or CWI treatment is delayed, they may immerse fully equipped hyperthermic football players in CWI and maintain acceptable Trec cooling rates. Otherwise, PADS should be removed preimmersion to ensure faster body core temperature cooling.
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