Unraveling the potential of “living low–training high”

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Living low–training high (LLTH) training models, where athletes live at low altitude but train at moderate to high altitude or in simulated hypoxia, have been shown to enhance endurance performance. This perspective article highlights a novel hypothesis: improvements from LLTH may not only stem from physiological adaptations but also from changes in the perception of effort (RPE). Drawing from neurophysiological models, case reports, and existing research on effort and hypoxia, the authors propose a psychophysiological framework for how LLTH may influence performance through adaptations in how effort is experienced and processed in the brain.

Hypoxia May Alter Effort Perception in Meaningful Ways

  • Training in hypoxia leads to elevated RPE during exercise due to increased neuromuscular fatigue, muscle pain, and respiratory discomfort.
  • However, when returning to normoxia, the same exercise is perceived as less effortful, potentially improving exercise tolerance and motivation.
  • This shift may support performance gains, particularly in endurance contexts.

Physiological and Neurophysiological Mechanisms of RPE in Hypoxia

  • LLTH may slow the development of neuromuscular fatigue, reducing the compensatory increase in central motor command needed to sustain performance.
  • Neurophysiological changes may occur in brain areas involved in effort perception, including the anterior cingulate cortex (ACC), supplementary motor area (SMA), and possibly the prefrontal cortex.
  • These areas are critical in motivation, decision-making, and action regulation, all relevant for exercise engagement and pacing.

Case Reports Support a Link Between Hypoxia and RPE

  • Short-term hypoxia exposure (Case 1) improved a master athlete’s running performance, with post-hypoxia exercise perceived as less fatiguing.
  • Prolonged hypoxia exposure (Case 2) did not increase output but reduced RPE during the same workload, suggesting altered perceptual responses after adaptation.

Effort as a Distinct Construct: Importance for Training Research

  • The authors argue RPE should be viewed as a unique psychological variable, separate from muscle pain or affective responses.
  • Using the corollary discharge model, they propose that perception of effort is generated by internal processing of motor command signals, rather than sensory feedback from pain or discomfort.
  • Increases in pain or discomfort in hypoxia may still indirectly elevate RPE by taxing attentional resources or emotional regulation.

Training in Hypoxia Likely Enhances Both Physiological and Psychological Resilience

  • LLTH protocols have been shown to enhance mitochondrial function, capillarization, and muscular efficiency.
  • These adaptations reduce metabolic stress and fatigue, likely contributing to a lower RPE at a given intensity post-intervention.
  • Hypoxia-induced improvements in muscle buffering, myoglobin content, and vascular remodeling may further support these effects.

Future Directions and Practical Implications

  • Researchers should clearly define and distinguish RPE from pain or affect when designing hypoxia studies.
  • LLTH may hold potential benefits not only for athletes, but also for older adults and clinical populations experiencing deconditioning.
  • Further research is needed to investigate brain-level adaptations, including changes in cortical areas involved in effort generation and regulation.

Burtscher, M., Álvarez-Herms, J., Burtscher, J., Strasser, B., Kopp, M., & Pageaux, B. (2025). Could the perception of effort help us unravel the potential of “living low–training high”? A perspective article. Journal of Sports Sciences. Advance online publication. https://doi.org/10.1080/02640414.2025.2474352