The role of impulse oscillometry in detecting airway dysfunction in athletes.

BACKGROUND: Impulse oscillometry (IOS) has previously been proposed to provide greater sensitivity than spirometry when employed with indirect bronchoprovocation testing for the diagnosis of airway dysfunction in athletes. However, this recommendation is based on a highly selected population of symptomatic patients. OBJECTIVE: To compare IOS, spirometry and respiratory symptoms following indirect bronchoprovocation in a screened cohort of athletes. METHODS: One hundred and one recreational athletes were recruited. Respiratory symptoms were assessed via the Dyspnoea-12 questionnaire. Spirometry and IOS were performed pre and post a eucapnic voluntary hyperpnoea (EVH) challenge. RESULTS: Ninety-four athletes completed the study. Sixteen athletes (17%) were positive for airway dysfunction based on spirometry (i.e. ≥ 10% fall in FEV1) and 17 athletes (18%) based on IOS (i.e. ≥ 50% increase in R5). Only nine athletes (10%) met both diagnostic thresholds. A poor relationship was observed between respiratory symptoms (i.e. Dyspnoea-12 score) and all spirometry and IOS variables. A direct relationship was observed between percentage change in R5 (r = 0.65), Z5 (r = 0.68), RF (r = 0.65), AX (r = 0.69) and the maximum fall in FEV1 (ΔFEV1max; p < 0.001). A weak relationship was observed between R20 (r = 0.27), X5 (r = 0.37) and ΔFEV1max (p < 0.01). CONCLUSION: Impulse oscillometry and spirometry do not concur precisely following indirect bronchoprovocation. However, IOS detects additional cases of airway dysfunction in athletes and therefore may provide diagnostic value in this population. Further work is required to establish diagnostic thresholds and fully determine the place of IOS in screening athletes for airway dysfunction.

Evidence of cardiac functional reserve upon exhaustion during incremental exercise to determine VO2max.

BACKGROUND: There remains considerable debate regarding the limiting factor(s) for maximal oxygen uptake (VO2max). Previous studies have shown that the central circulation may be the primary limiting factor for VO2max and that cardiac work increases beyond VO2max. AIM: We sought to evaluate whether the work of the heart limits VO2max during upright incremental cycle exercise to exhaustion. METHODS: Eight trained men completed two incremental exercise trials, each terminating with exercise at two different rates of work eliciting VO2max (MAX and SUPRAMAX). During each exercise trial we continuously recorded cardiac output using pulse-contour analysis calibrated with a lithium dilution method. Intra-arterial pressure was recorded from the radial artery while pulmonary gas exchange was measured continuously for an assessment of oxygen uptake. RESULTS: The workload during SUPRAMAX (mean±SD: 346.5±43.2 W) was 10% greater than that achieved during MAX (315±39.3 W). There was no significant difference between MAX and SUPRAMAX for Q (28.7 vs 29.4 L/min) or VO2 (4.3 vs 4.3 L/min). Mean arterial pressure was significantly higher during SUPRAMAX, corresponding to a higher cardiac power output (8.1 vs 8.5 W; p<0.06). CONCLUSIONS: Despite similar VO2 and Q, the greater cardiac work during SUPRAMAX supports the view that the heart is working submaximally at exhaustion during an incremental exercise test (MAX).

The effect of an even-pacing strategy on exercise tolerance in well-trained cyclists.

PURPOSE: Previous research has suggested that the optimal pacing strategy for self-paced exercise lasting >4 min is a uniform distribution of work, but this posit is not well established for prolonged endurance events. This study examined the utility of even pacing during 20 km cycling time trials (TTs). METHODS: Fifteen well-trained male cyclists ([Formula: see text]O2max = 4.80 ± 0.38 L min(-1)) completed three best effort self-paced (SP) simulated 20 km TTs, followed by two even-paced trials. In one even-paced trial, participants cycled to exhaustion (EPtlim) at a fixed intensity equivalent to their best SP performance. In the other EP trial, participants were instructed to maintain this target intensity for a distance of 20 km, but the actual intensity was free to vary depending on the effort and cadence of the cyclist (EP-maintained). Cardiorespiratory, blood lactate and perceptual (RPE and affect) measures were assessed throughout. RESULTS: Nine out of fifteen cyclists failed the EPtlim task, completing 51-83 % (10.3-15.3 km) of the work done in their SP trial. Failure as a result of even pacing was associated with a faster rise in blood lactate, attainment of a higher relative intensity during SP and a moderate fast starting strategy. This failure was independent of the nature of the even-paced task. CONCLUSION: By adopting an uneven, parabolic distribution of work, cyclists in this study were able to achieve an average intensity during self-paced exercise in excess of their maximum sustainable power output. A subsequent matched even-paced bout resulted in cumulative metabolic stress that could not be managed by moment-to-moment changes in power output. These results challenge the notion that strict even pacing is optimal for endurance time trial events.

Practical approach to exercise-induced bronchoconstriction in athletes.

Exercise-induced bronchoconstriction (EIB) is highly prevalent in athletes of all abilities and can impact on their health and performance. The majority of athletes with exertional dyspnoea will be initially assessed and managed in primary care. This report provides a practical and pragmatic approach to the assessment and management of a young athlete presenting with suspected EIB in this setting.

Inner dialogue and its relationship to perceived exertion during different running intensities.

This study examined the effect of low- and high-intensity running on cognitive thoughts (an individual's "inner dialogue") and its relationship to ratings of perceived exertion (RPE). Cognitive thoughts and RPE of eight runners were collected during a 40-min. treadmill run at either a low (50% peak running speed) or a high (70% peak running speed) exercise intensity. Runners were asked to place their thoughts into one of 10 themed categories, which incorporated a broad association/dissociation classification (Schomer, 1986, 1987). At a low intensity and RPE (6-10), runners reported more dissociative thoughts, while at a high intensity and RPE (16-20) they reported more associative thoughts. Further, although the runners may report a particular RPE, the inner dialogue and description of perceived exertion and fatigue may be markedly different. These findings suggest that an athlete's "internal dialogue" is intensity dependent, and may relate to the more urgent need to self-monitor physical changes and sensations during high-intensity running.

Reproducibility of pacing strategy during simulated 20-km cycling time trials in well-trained cyclists.

The aim of the study was to assess the reproducibility of pacing strategy, physiological and perceptual responses during simulated 20-km cycling time trials. Seventeen well-trained male cyclists ([Formula: see text] = 4.70 ± 0.33 L min(-1)) completed three 20-km time trials on a Velotron Pro cycle ergometer within a maximum duration of 14 days. During all trials power output, cadence and respiratory exchange were recorded throughout, rating of perceived exertion and affective response were recorded every 2-km and capillary blood was sampled and assayed for the determination of lactate concentration every 4-km. Power output data was assigned to 1-km 'bins' and expressed relative to the mean to quantify pacing strategy. Reproducibility of the pacing strategy and the whole trial mean responses was subsequently quantified using typical error (TE) with 90% confidence intervals. The pacing strategy adopted was similar across repeat trials, though there was a higher degree of variability at the start and end of the trial (TE = 6.6 and 6.8% for the first and last 1-km), and a trend for a progressively blunted start on repeat trials. The reproducibility of performance, cardiorespiratory and perceptual measures was good (TE range 1.0-4.0%), but blood lactate exhibited higher variability (TE = 17.7%). The results demonstrate the performance, perceptual and physiological response to self-paced 20-km time trials is reproducible in well-trained cyclists. Future research should acknowledge that variability in pacing strategy at the start and end of a self-paced bout is likely regardless of any intervention employed.

The effect of self- even- and variable-pacing strategies on the physiological and perceptual response to cycling.

It has been proposed that an even-pacing strategy is optimal for events lasting <120 s, but this assertion is not well-established. This study tested the hypothesis that even-paced cycling is less challenging than self- or variable-paced cycling. Ten well-trained male cyclists (VO2max, 4.89 ± 0.32 L min(-1)) completed a self-paced (SP) 20-km time trial followed by time- and work-matched even-paced (EP 100% SP mean power) and variable-paced (VP 142 and 72% SP mean power, 1:1.5 high:low power ratio) trials in a random, counterbalanced order. During all trials expired air and heart rate were analysed throughout, blood lactate was sampled every 4 km, and perceptual responses (rating of perceived exertion (RPE) and affect) were assessed every 2 km and post-trial. There were no whole trial statistically significant differences between trials for any of the respiratory variables measured, although there was a trend for higher RER's in VP compared to EP (P = 0.053). Blood lactate was lower in EP compared to VP (P = 0.001) and SP (P = 0.001), and higher in SP compared to VP (P = 0.008). RPE was lower, and affect more positive, in EP compared to both SP and VP (P > 0.05). The results of this study show that, for a time- and work-matched 20-km time trial, an even-paced strategy results in attenuated perturbations in the physiological response and lower perception of effort in comparison to self- and variable-paced strategies.

Managing respiratory problems in athletes.

Respiratory problems are common in athletes of all abilities and can significantly impact upon their health and performance. In this article, we provide an overview of respiratory physiology in athletes. We also discuss the assessment and management of common clinical respiratory conditions as they pertain to athletes, including airways disease, respiratory tract infection and pneumothorax. We focus on providing a pragmatic approach and highlight important caveats for the physician treating respiratory conditions in this highly specific population.

The influence of blood lactate sample site on exercise prescription.

The aims of this study were first to determine the level of agreement between the fingertip and earlobe for the measurement of blood lactate, and second, to examine whether these sample sites may be used interchangeably when distinguishing lactate parameters routinely used in the physiological assessment and exercise prescription. Twenty healthy men performed an incremental cycle ergometry step test. Capillary blood samples were taken simultaneously at the end of each increment from the earlobe and the fingertip to determine blood lactate concentration. The power output and the heart rate at different lactate parameters (LT, LT1, 2, and 4 mMol·L(-1)) were calculated from the lactate values. The average bias in blood lactate concentration measured from the fingertip and the earlobe was 9.2% with 95% of measures differing by between -24.9 and 58.7%. There were no significant differences between sample sites (p = 0.201); however, there was a strong positive relationship (R2 = 0.9455). At the different lactate parameters, there were no differences in determining the heart rate (except at 4 mMol·L(-1) [p = 0.028], equating to 2 b·min(-1)) and power output between sample sites. In conclusion, this high level of agreement and negligible differences in prescribing exercise using power output and heart rate from commonly used lactate parameters, determined from the earlobe and the fingertip indicate that these sample sites could be used interchangeably for physiological assessment during cycle ergometry.

Observer effects on the rating of perceived exertion and affect during exercise in recreationally active males.

This study examined the effect of introducing either a male or female observer on the ratings of perceived exertion (RPE) and affect of male runners during a moderate intensity running task. 10 moderately active men completed three 20-min. moderate intensity running trials at 60% of their peak treadmill running speed. Each participant completed three trials in random order: control, male-observed, and female-observed, where either the male or female observer joined the trial after 10 min. of the trial had elapsed, during which RPE and affect were monitored. The introduction of a female observer caused a significant decrease in RPE, whereas the introduction of a male observer caused a significant increase in RPE compared to the control trial. Affect was higher in the presence of both a male and female observer compared to control. It was concluded that there is a social, interpersonal, psychological dimension to RPE during exercise.

The effect of repeated endurance exercise on IL-6 and sIL-6R and their relationship with sensations of fatigue at rest.

Strenuous, prolonged exercise increases interleukin-6 (IL-6) release. The effect of IL-6 is dependent on the availability of IL-6 receptors. Few studies have addressed the impact of exercise on IL-6 receptor levels or procalcitonin (PCT), an indicator of systemic inflammation. Changes in these molecules may give insight into cytokine-related mechanisms underlying exercise-related fatigue. Thirteen trained male subjects partook in the study. They cycled a total distance of 468 km over 6 days. Blood samples were obtained prior to and immediately following Day 1 of the study and then each morning prior to exercise. Blood samples were analysed for plasma IL-6, soluble IL-6 receptor (sIL-6R), C-reactive protein (CRP), PCT, creatine kinase (CK) and cortisol concentrations. Subjects also completed mood state questionnaires each day prior to exercise. IL-6 was elevated immediately post-exercise on Day 1 but was unchanged at rest for the duration of the event. In contrast, sIL-6R, CRP, PCT and CK concentrations were unchanged immediately post-exercise on Day 1 but were significantly elevated at rest over the duration of the event compared with pre-event baseline. sIL-6R was highly correlated to CRP. Cortisol concentrations remained unchanged at all time points. In conclusion, strenuous, prolonged exercise stimulated an acute phase response which was maintained throughout the 6-day event. sIL-6R increase is associated with CRP and may affect subjective sensations of post-exercise fatigue at rest.

Approach to the diagnosis and management of suspected exercise-induced bronchoconstriction by primary care physicians.

BACKGROUND: Exercise-related respiratory symptoms in the diagnosis of exercise-induced bronchoconstriction (EIB) have poor predictive value. The aim of this study was to evaluate how athletes presenting with these symptoms are diagnosed and managed in primary care. METHODS: An electronic survey was distributed to a random selection of family practitioners in England. The survey was designed to assess the frequency with which family practitioners encounter adults with exercise-related respiratory symptoms and how they would approach diagnostic work-up and management. The survey also evaluated awareness of and access to diagnostic tests in this setting and general knowledge of prescribing asthma treatments to competitive athletes. RESULTS: 257 family practitioners completed the online survey. One-third of respondents indicated they encountered individuals with this problem at a frequency of more than one case per month. Over two-thirds of family practitioners chose investigation as an initial management strategy, while one-quarter would initiate treatment based on clinical information alone. PEFR pre- and post-exercise was the most commonly selected test for investigation (44%), followed by resting spirometry pre- and post-bronchodilator (35%). Short-acting beta2-agonists were the most frequently selected choice of treatment indicated by respondents (90%). CONCLUSION: Family practitioners encounter individuals with exercise-related respiratory symptoms commonly and although objective testing is often employed in diagnostic work-up, the tests most frequently utilised are not the most accurate for diagnosis of EIB. This diagnostic approach may be dictated by the reported lack of access to more precise testing methods, or may reflect a lack of dissemination or awareness of current evidence. Overall the findings have implications both for the management and hence welfare of athletes presenting with this problem to family practitioners and also for the competitive athletes requiring therapeutic use exemption.

Fatigue management in the preparation of Olympic athletes.

Fatigue is often a consequence of physical training and the effective management of fatigue by the coach and athlete is essential in optimizing adaptation and performance. In this paper, we explore a range of practical and contemporary methods of fatigue management for Olympic athletes. We assesses the scientific merit of methods for monitoring fatigue, including self-assessment of training load, self-scored questionnaires, and the usefulness of saliva and blood diagnostic markers for indicating fatigued and under-recovered athletes, effective nutrition and hydration strategies for optimizing recovery and short-term recovery methods. We conclude that well-accepted methods such as sufficient nutrition, hydration, and rest appear to be the most effective strategies for optimizing recovery in Olympic athletes.

Exercise-induced bronchoconstriction in athletes-should we screen?

The fact that exercise-induced bronchoconstriction (EIB) may be both over- and underdiagnosed in athletes has led to calls for widespread screening for the condition. This article assesses such a strategy by employing the standard framework used when evaluating any screening policy. This approach highlights a number of concerns and allows recommendations to help optimize the success of such a strategy if it were to be implemented.

Exercise-induced bronchoconstriction in athletes - A qualitative assessment of symptom perception.

BACKGROUND: A poor relationship between perceived respiratory symptoms and objective evidence of exercise-induced bronchoconstriction (EIB) in athletes is often reported; however, the reasons for this disconnect remain unclear. The primary aim of this study was to utilise a qualitative-analytical approach to compare respiratory symptoms in athletes with and without objectively confirmed EIB. METHODS: Endurance athletes who had previously undergone bronchoprovocation test screening for EIB were divided into sub-groups, based on the presence or absence of EIB ± heightened self-report of dyspnoea: (i) EIB-Dys- (ii) EIB + Dys+ (iii) EIB + Dys- (iv) EIB-Dys+. All athletes underwent a detailed semi-structured interview. RESULTS: Twenty athletes completed the study with an equal distribution in each sub-group (n = 5). Thematic analysis of individual narratives resulted in four over-arching themes: 1) Factors aggravating dyspnoea, 2) Exercise limitation, 3) Strategies to control dyspnoea, 4) Diagnostic accuracy. The anatomical location of symptoms varied between EIB + Dys + athletes and EIB-Dys + athletes. All EIB-Dys + reported significantly longer recovery times following high-intensity exercise in comparison to all other sub-groups. Finally, EIB + Dys + reported symptom improvement following beta-2 agonist therapy, whereas EIB-Dys + deemed treatment ineffective. CONCLUSION: A detailed qualitative approach to the assessment of breathlessness reveals few features that distinguish between EIB and non-EIB causes of exertional dyspnoea in athletes. Important differences that may provide value in clinical work-up include (i) location of symptoms, (ii) recovery time following exercise and (iii) response to beta-2 agonist therapy. Overall these findings may inform clinical evaluation and development of future questionnaires to aid clinic-based assessment of athletes with dyspnoea.

Eucapnic Voluntary Hyperpnea: Gold Standard for Diagnosing Exercise-Induced Bronchoconstriction in Athletes?

In athletes, a secure diagnos is of exercise-induced bronchoconstriction (EIB) is dependent on objective testing. Evaluating spirometric indices of airflow before and following an exercise bout is intuitively the optimal means for the diagnosis; however, this approach is recognized as having several key limitations. Accordingly, alternative indirect bronchoprovocation tests have been recommended as surrogate means for obtaining a diagnosis of EIB. Of these tests, it is often argued that the eucapnic voluntary hyperpnea (EVH) challenge represents the 'gold standard'. This article provides a state-of-the-art review of EVH, including an overview of the test methodology and its interpretation. We also address the performance of EVH against the other functional and clinical approaches commonly adopted for the diagnosis of EIB. The published evidence supports a key role for EVH in the diagnostic algorithm for EIB testing in athletes. However, its wide sensitivity and specificity and poor repeatability preclude EVH from being termed a 'gold standard' test for EIB.

Diagnosing exercise-induced bronchoconstriction with eucapnic voluntary hyperpnea: is one test enough?

BACKGROUND: In athletic individuals, a secure diagnosis of exercise-induced bronchoconstriction (EIB) is dependent on objective testing. Indirect bronchoprovocation testing is often used in this context and eucapnic voluntary hyperpnea (EVH) testing is recommended for this purpose, yet the short-term reproducibility of EVH is yet to be appropriately established. OBJECTIVE: The aim of this study was to evaluate the reproducibility of EVH in a cohort of recreational athletes. METHODS: A cohort of recreational athletes (n = 32) attended the laboratory on two occasions to complete an EVH challenge, separated by a period of 14 or 21 days. Spirometry and impulse oscillometry was performed before and after EVH. Training load was maintained between visits. RESULTS: Prechallenge lung function was similar at both visits (P > .05). No significant difference was observed in maximum change in FEV1 (ΔFEV1max) after EVH between visits (P > .05), and test-retest ΔFEV1max was correlated (intraclass correlation coefficient = 0.81; r(2) = 0.66; P = .001). Poor diagnostic reliability was observed between tests; 11 athletes were diagnosed with EIB (on the basis of ΔFEV1max ≥10%) at visit 1 and at visit 2. However, only 7 athletes were positive at both visits. Although there was a small mean difference in ΔFEV1max between tests (-0.6%), there were wide limits of agreement (-10.7% to 9.5%). Likewise, similar results were observed for impulse oscillometry between visits. CONCLUSIONS: In a cohort of recreational athletes, EVH demonstrated poor clinical reproducibility for the diagnosis of EIB. These findings highlight a need for caution when confirming or refuting EIB on the basis of a single indirect bronchoprovocation challenge. When encountering patients with mild or borderline EIB, we recommend that more than one EVH test is performed to exclude or confirm a diagnosis.

Exercise-conditioned plasma attenuates nuclear concentrations of DNA methyltransferase 3B in human peripheral blood mononuclear cells.

DNA methylation is modifiable by acute and chronic exercise. DNA methyltransferases (DNMT) catalyze this process; however, there is a lack of literature concerning the specific mechanisms by which exercise-induced modifications occur. Interleukin 6 (IL-6) stimulation of various cell lines has been shown to augment DNMT expression and nuclear translocation, which suggests a possible pathway by which exercise is able to elicit changes in epigenetic enzymes. The present study sought to elucidate the response of the de novo methyltransferases DNMT3A and DNMT3B to circulatory factors found in plasma isolated from whole blood before and after 120-min of treadmill running at an intensity of 60% of individual velocity at V˙O2max (vV˙O2max) interspersed with 30-sec sprints at 90% of vV˙O2max every 10-min. Peripheral blood mononuclear cells (PBMCs) isolated from a resting participant were incubated with plasma isolated from exercising participants (n = 10) or recombinant IL-6 (rIL-6), followed by nuclear protein extraction and quantification of DNMT3A and DNMT3B concentrations. Nuclear concentrations of DNMT3B significantly decreased following the experimental protocol (P = 0.03), with no change observed in DNMT3A (P = 0.514).Various concentrations of rIL-6 caused an elevation in both DNMT3A and DNMT3B nuclear concentration compared with the blank control. The conflicting results between exercising and rIL-6 conditions suggests that IL-6 does regulate DNMT nuclear transport, however, other plasma mediators may also exert significant influence on the nuclear concentrations of these enzymes.