Season-long heart rate variability tracking reveals autonomic imbalance in American college football players

As part of my PhD work at Alabama, we tracked HRV in football players from day 1 of preseason training through to the national championship. A practical summary of some key findings follow the full-text link below.

Fluctuations in HRV are expected throughout a season. However, chronically suppressed values are cause for concern. Sustained parasympathetic hypoactivity is associated with various pathological conditions and is a hallmark of stress and impaired recovery in athletes.

We learned from spring camp that day-to-day HRV recovery was delayed in linemen vs. the smaller and more aerobically fit skill players. Thus, we anticipated that linemen would be more susceptible to attenuated HRV throughout the season.

HRV started to decline by week 6 of the competitive period for linemen. A couple notable events occurred here: 1) the first of 5 consecutive SEC match-ups vs Top 25 nationally-ranked opponents and 2) the week of mid-term exams for many players.

Although significant group-level reductions for linemen weren’t observed until later, key players showed descending HRV by mid-season, in the absence of changes in PlayerLoad. Suppressed HRV preceded illness and injury in 2 starters. Temporary rest restored HRV.

Group-level reductions occurred during an intensive camp-style preparation period for the college football playoffs following the SEC championship. Most players took a hit to their HRV, but linemen were hit the hardest. Note magnitudes of the effect sizes in the table below.

HRV remain suppressed for linemen through prep weeks for the national semi-final and the national championship. Smaller decrements (non-significant) were observed for skill players. In addition to accumulating physical stress, psycho-emotional factors (pre-competitive anxiety, pressure to perform, media attention, etc) likely contributed.

Although we emphasize the toll of a season on linemen, some skill players also showed suppressed values. The table below shows the rate of change in HRV for all players. 25% of skill and 63% of linemen showed sig. descending HRV patterns throughout the season.

Linemen experience hypertension, arterial stiffening, and pathologic LV hypertrophy following 1 or more seasons. These maladaptations are possibly preceded by ANS imbalance. We hypothesize that larger players showing the worst HRV profiles suffer the greatest decrement in cardiovascular health markers.

If so, intervening when a decreasing HRV pattern is observed may not only be relevant to performance (limiting fatigue, injury-, and infection-risk), it may also help mitigate the cardiovascular toll of playing football at such a high level. Seeking funding to explore this in the future.

The findings highlight potential deficiencies in or greater taxation to the coping capacity of linemen vs. smaller players. Factors hypothesized to contribute to more prevalent ANS imbalance in linemen and potential implications for health and performance are summarized below.

Linemen need careful attention and monitoring. We need strategies to prevent ANS imbalance from occurring (load management, aerobic capacity, treatment of health conditions like sleep apnea, etc) and we need restorative methods to implement if it occurs.

Tracking HRV with a mobile app was inexpensive and easy. Time-demand from players was ~3 min/week while waiting to get taped. Though sub-optimal relative to post-waking measures, this approach enabled timely detection of descending patterns, which may be useful for guiding interventions relevant to player health and wellbeing.

Though a better understanding of the health and performance ramifications of suppressed HRV in football players is needed, a descending pattern may serve as an easily identifiable red flag requiring attention from performance and medical staff.

Cardiac-Autonomic and Hemodynamic Responses to a Hypertonic, Sugar-Sweetened Sports Beverage in Physically Active Men

Short summary of and full-text access to a new study from our lab.

Link to Full Text:

Context: we previously resorted to standardized HRV measures performed in the athletic training room with college football players to overcome non-compliance with post-waking tests.

Problem: pre-training hydration practices confound HRV measures. Players typically opt for cold bottles of water or Gatorade. Thus, we needed to determine how much and for how long these drinks impacted HRV.

Findings: Gatorade had small effects that lasted about 45 min. Effects of water were larger and persisted for 60 min.

Key points:

If measuring HRV in a lab/clinic/training facility, be mindful of recent fluid ingestion.
HRV measures obtained within 60 min of 591 ml water or 45 min of an equal volume of Gatorade will be capturing their physiology effects and result in falsely elevated values. This would result in misinterpretation of autonomic status.

Effect of Competitive Status and Experience on Heart Rate Variability Profiles in Collegiate Sprint-Swimmers

Here’s a new paper from my time at Bama. A practical summary follows the link and abstract below.

Link to free full text:


When first getting started with tracking HRV in athletes, the inter-individual variation in trend characteristics can be confusing. Some athletes will display very high values and others will show lower values. Likewise, some will show quite stable values while others display substantial day-to-day variation. Naturally, the following question arises: why do some athletes have higher and more stable values than others?

Collegiate swim rosters typically include a mixed roster of athletes (males and females with a broad range of experience and skill). In this investigation we compared HRV trend characteristics between the national-level (including 6 Olympians) and conference-level sprint-swimmers throughout 4 weeks of standardized preparatory training. We also obtained details of individual training history.

The main findings were that national-level swimmers had higher and more stable HRV (higher mean LnRMSSD, lower LnRMSSD coefficient of variation) than their conference-level teammates. Differences in trend characteristics were attributable to a greater history of training and competing among the national-level swimmers (i.e., greater training age).

Whether these findings can be explained by greater aerobic fitness (we don’t think so), greater familiarity with training (possibly), or chronic physiological adaptations (possibly) among the higher-level swimmers is unclear.

The findings may be of some practical use for coaches when interpreted with previous work (see links below). For example, preliminary expectations with HRV monitoring should be that higher-level swimmers will display higher and more stable values throughout training and vice-versa for lower-level athletes. This may be interpreted to mean that the higher-level athletes could tolerate greater loads or that the lower-level athletes may need reduced loads. However, it is unclear if these training modifications would offer any performance/adaptation advantage. In addition, a higher-level athlete showing lower and less-stable values may be cause for concern (fatigue, stress, detraining, etc. depending on context). Whereas a lower-level athlete displaying higher and more stable values is likely adapting well to the training.

We’ve previously assessed how overload and tapering impact HRV in sprint-swimmers here.

We’ve previously assessed associations between subjective indicators of recovery and daily HRV in sprint-swimmers here.

Heart rate-based indices to detect parasympathetic hyperactivity in functionally overreached athletes. A meta-analysis

Our new meta-analysis determined that parasympathetic hyperactivity in overreached endurance athletes is best detected using weekly averaged versus isolated HRV values and in the standing versus supine position.

Thanks to Agustín Manresa-Rocamora, Antonio Casanova-Lizón, Juan A. Ballester-Ferrer, José M. Sarabia, Francisco J. Vera-Garcia, and Manuel Moya-Ramón for inviting my collaboration.

The full text can be accessed at the link below:

Ultrashort Versus Criterion Heart Rate Variability Among International-Level Girls’ Field Hockey Players

Here’s our latest study comparing 1 min vs 5 min HRV throughout a 4-week camp in international-level girls field hockey players. Values were highly correlated, showed similar responses to load, & similar associations with fitness. Practically same insight, 80% less time. Thanks to Drs. Gonzalez-Fimbres and Hernandez-Cruz for the collaboration.

Link to full free text below:


Heart Rate Variability in College Football Players throughout Preseason Camp in the Heat

Here’s a quick look at our latest study examining cardiac-autonomic responses to preseason camp in the heat among college football players. The free full text can be accessed here: Heart rate variability in college football players throughout preseason camp in the heat IJSM

Intensive training periods tend to increase RHR and decrease HRV, reflecting stress and fatigue. However, adaptations to heat exposure (e.g., plasma volume expansion) tend to have the opposite effects. So we wanted to see what happens when players were exposed to both intense training and intense heat stress during preseason camp.

Despite increases in perceived fatigue throughout the 2-week period, RHR and HRV reflected responses consistent with heat acclimation.

HRV initially decreased in linemen, then peaked after a day of rest. Non-linemen faired a little better with smaller decrements in perceived fatigue and more frequent day-to-day improvements in RHR and HRV.

These results indicate that heart rate parameters and perceived fatigue are independent markers of training status, and that desirable cardiovascular adaptations can occur in the presence of soreness and fatigue.

This is especially important for tech companies who try to infer recovery status from HRV alone. As HRV improved throughout camp, an app’s algorithm would report to coaches that players are well-recovered. Given that no player feels well-recovered during preseason camp in the heat, the technology suddenly loses credibility for being wrong and will likely be dismissed.

This is unfortunate because the heart rate parameters are likely reflecting important adaptations that may indicate better tolerance to training in the heat, a reduced exercising heart rate, and improved fitness. Thus, I encourage users to ignore “recovery” scores and interpret the data in appropriate context.


We aimed to characterize cardiac-autonomic responses to a 13-day preseason camp in the heat among an American college football team. Players were categorized as linemen (n=10) and non-linemen (n=18). RHR, natural logarithm of the root-mean square of successive differences multiplied by twenty (LnRMSSD), and subjective wellbeing (LnWellness) were acquired daily. Effect sizes±90% confidence interval showed that for linemen, LnRMSSD decreased (moderate) on day 2 (71.2±10.4) and increased (moderate) on day 12 (87.1±11.2) relative to day 1 (77.9±11.2) while RHR decreased (small–moderate) on days 6, 7, and 12 (67.7±9.3–70.4±5.5 b∙min-1) relative to day 1 (77.1±10.1 b∙min-1). For non-linemen, LnRMSSD increased (small–large) on days 3–5, 7, 12, and 13 (83.4±6.8–87.6±8.5) relative to day 1 (80.0±6.5) while RHR decreased (small–large) on days 3–9, 12, and 13 (62.1±5.2–67.9±8.1 b∙min-1) relative to day 1 (70.8±6.2 b∙min-1). Decrements in LnWellness were observed on days 4–10 and 13 for linemen (moderate) and on days 6–9, 12, and 13 for non-linemen (small–moderate). Despite reductions in LnWellness, cardiac-autonomic parameters demonstrated responses consistent with heat-acclimation, which possibly attenuated fatigue-related decrements.

HRV Monitoring During Strength and High-Intensity Interval Training Overload Microcycles

Thanks to Christoph Schneider for inviting my collaboration on this new study from his PhD work. The full-text can be viewed here.

Heart Rate Variability Monitoring During Strength and High-Intensity Interval Training Overload Microcycles


Objective: In two independent study arms, we determine the effects of strength training (ST) and high-intensity interval training (HIIT) overload on cardiac autonomic modulation by measuring heart rate (HR) and vagal heart rate variability (HRV).

Methods: In the study, 37 well-trained athletes (ST: 7 female, 12 male; HIIT: 9 female, 9 male) were subjected to orthostatic tests (HR and HRV recordings) each day during a 4-day baseline period, a 6-day overload microcycle, and a 4-day recovery period. Discipline-specific performance was assessed before and 1 and 4 days after training.

Results: Following ST overload, supine HR, and vagal HRV (Ln RMSSD) were clearly increased and decreased (small effects), respectively, and the standing recordings remained unchanged. In contrast, HIIT overload resulted in decreased HR and increased Ln RMSSD in the standing position (small effects), whereas supine recordings remained unaltered. During the recovery period, these responses were reversed (ST: small effects, HIIT: trivial to small effects). The correlations between changes in HR, vagal HRV measures, and performance were weak or inconsistent. At the group and individual levels, moderate to strong negative correlations were found between HR and Ln RMSSD when analyzing changes between testing days (ST: supine and standing position, HIIT: standing position) and individual time series, respectively. Use of rolling 2–4-day averages enabled more precise estimation of mean changes with smaller confidence intervals compared to single-day values of HR or Ln RMSSD. However, the use of averaged values displayed unclear effects for evaluating associations between HR, vagal HRV measures, and performance changes, and have the potential to be detrimental for classification of individual short-term responses.

Conclusion: Measures of HR and Ln RMSSD during an orthostatic test could reveal different autonomic responses following ST or HIIT which may not be discovered by supine or standing measures alone. However, these autonomic changes were not consistently related to short-term changes in performance and the use of rolling averages may alter these relationships differently on group and individual level.


New Podcast Episode: HRV monitoring in team sports

Thanks to Dr. Marc Bubbs for having me on the show to discuss HRV in team sports. Details and episode links below.

In Season 3, Episode 7 Dr. Bubbs interviews Dr. Andrew Flatt PhD to discuss applications of heart rate variability (HRV) monitoring in team sport athletes. Dr. Flatt reviews the basic physiology of HRV, how pre-season testing can inform your training and recovery plans, how in-season monitoring influences decision making, and new findings on HRV results in larger athletes, such as linemen in American football. Dr. Flatt also discusses how the “other 22-hours” in the day – sleep, long-haul travel, mental and emotional stress, etc. – impact the nervous system and HRV measures, and finally provides some practical tips on how to collect HRV measurements, validated apps, and red flags to avoid when interpreting results.

Summary of This Episode

7:00 – What Is HRV?

7:45 – What impacts HRV scores in athletes

11:00 – Pre-season HRV trends in team sport athletes

13:20 – Olympic vs. national level swimmer HRV values

25:00 – In-season monitoring in collegiate football players

33:00 – Strategies for improving recovery as competitive season progresses

40:00 – Monitoring – a tool to start a conversation

46:30 – Different “apps” to implement with clients

57:00 – Evolution of research in HRV and team sports

Monitoring Ultra-Short HRV and HR-Running Speed Index in an Elite Soccer Player: A Case Study

Here’s a recent case study featuring HRV changes in a pro soccer player throughout preseason training. Thanks to my colleague Alirezza Rabbani for inviting my collaboration on this one.

The main findings were that post-waking HRV and the HR-Running Speed Index (an indicator of aerobic fitness) during the warm-up jog progressively improved and were highly correlated. Additionally, we found that 1-min HRV measures were no different than 5-min HRV measures. The paper is free open-access at the link below.

Monitoring Ultra-Short Heart Rate Variability and Heart Rate-Running Speed Index in an Elite Soccer Player: A Case Study

Case study HRV RSI

Monitoring Ultra-Short Heart Rate Variability and Heart Rate-Running Speed Index in an Elite Soccer Player: A Case Study

Effects of varying training load on HRV and running performance among an Olympic rugby sevens team

This study is the first of a few collaborations between Dan Howells and I involving HRV in elite rugby sevens players. Here we evaluated HRV and running performance responses  to peak training loads during preparation for the 2016 Olympic games. A practical summary follows the abstract below.

Effects of varying training load on HRV and running performance among an Olympic rugby sevens team

JSAMS Abstract Flatt Howells HRV rugby sevens

How do elite seven’s players respond to substantial increments in training load? Based on previous studies, we’d expect the weekly LnRMSSD mean (LnRMSSDm) to decrease and the coefficient of variation (LnRMSSDcv) to increase relative to baseline. We’ve observed this in collegiate soccer players and sprint-swimmers.

In contrast to this hypothesis, the players showed no change in LnRMSSDmean throughout two weeks of intensified training relative to a baseline week of low loads. LnRMSSDcv demonstrated a small increase during the first week of increased load (expected response) but then showed a moderate decrease during the second week of increased load, which involved greater loads than the previous week (unexpected response).

No change (or an increase) in LnRMSSDm and a reduction in LnRMSSDcv is typically observed when training loads are reduced. Less training stress results in less fluctuations in LnRMSSD. However, these players demonstrated less fluctuation in LnRMSSD despite significant increments in training load.

The discrepancy here appears to be related to how players are tolerating and adapting to the training load. We often assume that increased loads will result in fatigue accumulation and temporary negative responses. However, these elite players demonstrated no reductions in subjective indicators of recovery status during the weeks of increased load. Additionally, there was no significant decrement in running performance (maximum aerobic speed) mid-way through the intensified microcycles.

Thus, the preservation of autonomic activity (no change in LnRMSSDm) and less fluctuations (reduced LnRMSSDcv) seem to reflect a postive coping response to the training. In fact, individuals who demonstrated the lowest LnRMSSDcv during week 1 of increased load showed the most favorable changes in running performance (r = -0.74).

This is yet another study that demonstrates that reduced fluctuations in LnRMSSD (i.e., decrease in LnRMSSDcv) is associated with positive training responses in athletes.

The Practical Implications of the study were:

•When evaluated as a group, LnRMSSDcv may be a more sensitive training response marker than LnRMSSDm during training load variations among elite players.

•LnRMSSDcv did not display a linear dose–response relationship with training load. Rather, LnRMSSDcv seems to reflect an adaptive physiological response to the imposed training stimulus which may be useful for identifying individuals responding undesirably to training.

•Elite rugby players presenting large day-to-day fluctuations in LnRMSSD in response to training load variation should be monitored closely for performance decrements, particularly when nearing important competitions.