Molphy, J., Dickinson, J., Chester, N., Loosemore, M. and Whyte, G. (2019). The Effects of Inhaled Terbutaline on 3-km Running Time-Trial Performance. International journal of sports physiology and performance [Online]. Available at: https://doi.org/10.1123/ijspp.2018-0633.
Terbutaline is a prohibited drug except for athletes with a therapeutic use exemption certificate; terbutaline’s effects on endurance performance are relatively unknown.
To investigate the effects of two therapeutic (2mg; 4mg) inhaled doses of terbutaline on 3km running time-trial performance.
Eight males (24.3±2.4yrs; 77.6±8kg; 179.5±4.3cm) and eight females (22.4±3yrs; 58.6±6kg; 163±9.2cm) free from respiratory disease and illness provided written informed consent. Participants completed 3 km running time-trials on a non-motorised treadmill on three separate occasions following placebo, 2 mg or 4 mg inhaled terbutaline, in a single-blind, repeated-measures design. Urine samples (15mins post-exercise) were analysed for terbutaline concentration. Data were analysed using one-way repeated measures ANOVA, significance was set at p<0.05 for all analyses.
No differences were observed for completion times (1103±201; 1106±195; 1098±165s; P=0.913) for the placebo trial, the 2mg inhaled trial and the 4mg inhaled trial, respectively. Lactate values were higher (P=0.02) following 4mg terbutaline (10.7±2.3mmol·L-1) vs. placebo (8.9±1.8mmol·L-1). FEV1 values were greater following inhalation of 2mg (5.08±0.2; P=0.01) and 4mg terbutaline (5.07±0.2; P=0.02) compared to placebo (4.83±0.5L) post-inhalation. Urinary terbutaline concentrations were mean (306±288ng·mL-1; 435±410ng·mL-1; P=0.2) and peak (956ng·mL-1; 1244ng·mL-1) following 2mg and 4mg inhaled terbutaline, respectively. No differences were observed between the male and female participants.
Therapeutic dosing of terbutaline does not lead to an improvement in 3 km running performance despite significantly increased FEV1. Our findings suggest that athletes using inhaled terbutaline at high therapeutic doses to treat asthma will not gain an ergogenic advantage during 3 km running performance.
Merlini, M., Marco, B., Marcora, S. and Dickinson, J. (2019). The Effect of 1600 μg Inhaled Salbutamol Administration on 30 m Sprint Performance Pre and Post a Yo-Yo Intermittent Running Test in Football Players. Journal of Sports Science and Medicine [Online] 18. Available at: https://www.jssm.org/hfabst.php?id=jssm-18-716.xml.
The purpose of the study was to investigate the effect of inhaling 1600 μg of salbutamol (SAL) on 30 m sprint before and after the Yo-Yo Intermittent Recovery test. In a randomised cross over single blind study 13 male non-asthmatic, football players volunteered (mean ± SD; age 18.1 ± 0.9 years; weight 69.5 ± 8.3 kg; height 1.78 ± 0.07 m). Participants completed two visits and were randomly assigned to either (SAL) or (PLA) treatment and performed a set of three sprints of 30 m before and after the Yo-Yo Intermittent Recovery Test (Yo-Yo IRT). Best sprint and mean sprint were analysed in addition to the distance covered during the Yo-Yo IRT; rating of perceived exertion and heart rate were collected at the end of each level completed. Repeated measures ANOVA were performed to investigate changes in performance between groups. Following the inhalation of supra-therapeutic salbutamol dose (1600 μg) neither 30 m sprint time (PLA 4.43 ± 0.14 s; SAL 4.44 ± 0.15 s, p = 0.76) nor distance covered in the Yo-Yo IRT test reported significant variation between PLA conditions (1660 ± 217 m) and SAL (1610 ± 229 m, p = 0.16). Moreover, lactate values, heart rate and RPE did not differ significantly between groups. The inhalation of 1600 μg salbutamol does not enhance 30 m sprint performance in non-fatigued and fatigue conditions. Our findings suggest when football players acutely inhale double the permitted dose of salbutamol, as indicated in the World Anti-Doping Agency List of Prohibited Substances and Methods, they will not experience improvements in sprint or endurance performance.
Allen, H., Hull, J., O’Hara, J., Dickinson, J. and Price, O. (2019). Dietary nitrate supplementation increases fractional exhaled nitric oxide: implications for the assessment of airway health in athletes. Thorax [Online] 74:A97. Available at: http://dx.doi.org/10.1136/thorax-2019-BTSabstracts2019.160.
Background: Fractional exhaled nitric oxide (FeNO) is a simple tool that has an established role in the assessment of airway inflammation in athletes. Specifically, FeNO provides information concerning asthma phenotypes, aetiology of respiratory symptoms, response to anti-inflammatory agents, course of disease and adherence to medication. It is recognised that FeNO can be influenced by a variety of external factors (e.g. atopic status, exercise, respiratory tract infection), however, there remains limited research concerning the impact of dietary nitrate ingestion. The primary aim of this study was therefore to evaluate the effect of acute dietary nitrate supplementation on FeNO and resting pulmonary function parameters.
Method: The study was conducted as a randomised double-blind placebo-controlled trial. Thirty male endurance trained athletes (age: 28 ± 6 yrs; BMI: 23 ± 2 kg.m-2) free from cardio-respiratory and metabolic disease, and stable at time of study entry (i.e. entirely asymptomatic without recent respiratory tract infection) attended the laboratory on two separate occasions. On arrival to the laboratory, athletes consumed either 140ml nitrate-rich beetroot juice (15.2 mmol nitrate) (NIT) or nitrate-depleted beetroot juice (0 mmol nitrate) (PLA). In accordance with international guidelines all athletes performed resting FeNO and forced spirometry (2.5hrs post ingestion). Airway inflammation was evaluated using established FeNO thresholds: (intermediate [≥25ppb] and high [>50ppb]). Results: All athletes demonstrated normal baseline lung function (FEV1 % predicted >80%). A three-fold rise in resting FeNO was observed following NIT (median [IQR]): 32ppb  in comparison to PLA: 10ppb  (P<0.001). Twenty-two athletes (73%) presented with raised FeNO following NIT (intermediate: n = 13; high: n = 9) in comparison to four athletes (13%) following PLA (intermediate: n = 2; high: n = 2). Despite this, no difference was observed in any pulmonary function parameters between visits (P>0.05). Conclusion: Dietary nitrate ingestion should be considered when employing FeNO for the assessment of airway health in athletes. Our findings have implications concerning the decision to initiate or modify inhaler therapy. Further research is therefore required to determine the impact of chronic dietary nitrate ingestion on pulmonary function and bronchoprovocation testing in athletes with pre-existing asthma and/or exercise-induced bronchoconstriction.
Parnell, M., Gee, I., Foweather, L., Whyte, G., Knowles, Z. and Dickinson, J. (2019). The Impact of Environmental Tobacco Smoke Exposure on Cardiorespiratory Fitness in Children: A Pilot Study. International Journal of Environmental Impacts [Online] 2:240-248. Available at: https://doi.org/10.2495/EI-V2-N3-240-248.
Environmental tobacco smoke (ETS) in indoor air is a substantial risk factor for many health issues. Children are particularly susceptible to ETS with increased risk of asthma attacks, respiratory infections and sudden infant death syndrome. The health effects of ETS are well researched in adults, but
few studies examine the impact on children’s cardiorespiratory fitness (CRF). CRF has been shown to be a useful biomarker for monitoring health effects which would normally be too subtle to identify at rest. In adults, ETS has been shown to reduce CRF, and children may be at greater risk due to high respiration rates and developing organs. This preliminary research tests the hypothesis that ETS has a detrimental impact on CRF in children. Twenty-five children (9–11 years) from one Merseyside primary school were recruited. ETS exposure was determined by parental surveys and coupled with children’s exhaled carbon monoxide concentration. CRF was determined using a VO2 peak test, with lung function assessed using standard spirometry, and fractional exhaled nitric oxide (FeNO) provided an indication of lung inflammation. Initial results show that children exposed to ETS had statically lower CRF scores (p = 0.048) and were more likely to be classified as ‘unfit’ compared to children not exposed. A negative correlation was found between the number of cigarettes smoked at home and children’s CRF (r = −0.526, p = 0.008), suggesting a possible dose–response relationship. Spirometry and FeNO values were not statistically different between groups. Results indicate that ETS exposure is likely to be detrimental to children’s CRF. They highlight the need for further work, on a larger dataset that will allow more robust analysis with greater statistical power. To the author’s knowledge, this study is the first of its kind to use laboratory-based fitness measurements to explore associations between ETS and CRF in children
Jackson, A., Allen, H., Hull, J., Backhouse, S., Hopker, J., Price, O. and Dickinson, J. (2019). Over or under-detection? A comparison of exercise and eucapnic voluntary hyperpnoea in the evaluation of exercise-induced bronchoconstriction. Allergy [Online]. Available at: https://doi.org/10.1111/all.14005.
Background: The most appropriate objective bronchoprovocation challenge in the evaluation of exercise-induced bronchoconstriction (EIB) remains debated. Standardising minute ventilation and environmental conditions during an exercise challenge test (EX) is challenging, whereas it has recently been proposed that eucapnic voluntary hyperpnoea (EVH) may be overly sensitive. The primary aim of this study was therefore to compare the airway response to EX in a dry environment (25% RH) and EVH. An evaluation of current and revised diagnostic thresholds was undertaken to determine the impact of any proposed modification to EIB screening outcome.
Methods: In randomised order, sixty-three recreational athletes (male: n = 47) (training 9 ± 4 hrs/week) attended the laboratory on two separate occasions to complete either an EX challenge (6-min high-intensity cycling exercise at >80% max heart rate) in an environmental chamber (16oC, 25% relative humidity), and a EVH challenge (6-min maximal ventilation of a dry compressed gas mixture: 21% O2, 5% CO2, N2 balanced). Spirometry was performed at baseline and 3, 5, 7, 10 and 15 minutes post challenge test in accordance with international guidelines. A positive diagnosis was defined by ≥10% fall in FEV1 at two consecutive time-points for both EX and EVH and ≥15% fall in FEV1 at one time-point for EVH.
Results: The mean fall in lung function following EVH (-7.9 ± 6.9%) was greater in comparison to EX (-1.9 ± 7.1; P<0.01). A moderate positive correlation was observed between tests (ρ = 0.46, P<0.01), however the mean bias was 6.1% and the data exhibited wide limits of agreement (+5.3 to -17.5%). Thirteen (21%) participants had a ≥10% fall in FEV1 following EVH, of which five were positive to EX. Nine (14%) participants had a >15% FEV1 fall following EVH, of which four were positive to EX.
Conclusion: Our findings indicate that EVH consistently induces a greater fall in FEV1 in comparison to EX. Applying a 10% fall in FEV1 cut-off for EVH results in greater diagnostic sensitivity, whereas a 15% fall in FEV1 cut-off improves diagnostic specificity. Future population-based research evaluating the normative response to indirect bronchoprovocation in athletes remains a priority.
Merlini, M., Whyte, G., Marcora, S., Loosemore, M., Chester, N. and Dickinson, J. (2019). Improved Sprint Performance With Inhaled Long-Acting Β2-Agonists Combined With Resistance Exercise. International Journal of Sports Physiology and Performance [Online]. Available at: https://doi.org/10.1123/ijspp.2018-0921.
To investigate the impact of twice daily inhalation of 100 μg of salmeterol or 12 μg of formoterol in addition to a strength and power training programme over a 5-wk period on 30-m sprint, strength, power, mood, stress, and skinfold thickness.
In a randomized single-blind study, 23 male and 15 female nonasthmatic, recreationally active individuals were recruited (mean ± SD age 26.3 ± 5.4 y, weight 76.2 ± 11.5 kg, height 176.9 ± 8.5 cm). Participants completed 3 standardized whole-body strength and power training sessions per week for 5 wk. During the 5-wk training period they were assigned to a salmeterol (SAL), formoterol (FOR), or placebo (PLA) group. Participants used their inhaler twice per day as instructed and completed assessments of sprint, strength, and power at baseline and 1 wk after cessation of the training program. The assessments included 30-m sprint, vertical jump, 1-repetition-maximum (1RM) bench press, 1RM leg press, peak torque flexion and extension, anthropometric evaluation, and Rest-Q questionnaires.
After 5 wk of strength and power training, 30-m sprint time reduced in FOR (0.29 ± 0.11 s, P = .049) and SAL (0.35 ± 0.05 s, P = .040) groups compared with PLA (+0.01 ± 0.11 s). No significant change was found in other assessments of strength, mood, or skinfold thickness.
When strength and power training is combined with the inhalation of FOR or SAL over a 5-wk period, moderately trained individuals experience an improvement in 30-m sprint performance.
Jackson, A., Allen, H., Hull, J., Hopker, J., Backhouse, S., Price, O. and Dickinson, J. (2019). Diagnosing exercise‐induced bronchoconstriction: Over‐or under‐detection?. Allergy [Online]. Available at: https://doi.org/10.1111/all.14005.
Massaroni, C., Piaia Silvatti, A., Levai, I., Dickinson, J., Winter, S., Schena, E. and Silvestri, S. (2018). Comparison of marker models for the analysis of the volume variation and thoracoabdominal motion pattern in untrained and trained participants. Journal of Biomechanics [Online] 76:247-252. Available at: https://doi.org/10.1016/j.jbiomech.2018.05.036.
Respiratory assessment and the biomechanical analysis of chest and abdomen motion during
breathing can be carried out using motion capture systems. An advantage of this methodology is
that it allows analysis of compartmental breathing volumes, thoraco-abdominal patterns,
percentage contribution of each compartment and the coordination between compartments. In the
literature, mainly, two marker models are reported, a full marker model of 89 markers placed on
the trunk and a reduced marker model with 32 markers. However, in practice, positioning and
post-process a large number of markers on the trunk can be time-consuming. In this study, the
full marker model was compared against the one that uses a reduced number of markers, in order
to evaluate i) their capability to obtain respiratory parameters (breath-by-breath tidal volumes)
and thoracoabdominal motion pattern (compartmental percentage contributions, and coordination
between compartments) during quiet breathing, and ii) their response in different groups such as
trained and untrained, male and female. Although tests revealed strong correlations of the tidal volume values in all the groups (R2
>0.93), the reduced model underestimated the trunk volume compared with the 89 marker model. The
highest underestimation was found in trained males (bias of 0.43 L). The three-way ANOVA test
showed that the model did not influence the evaluation of compartmental contributions and the
32 marker model was adequate to distinguish thoracoabdominal breathing pattern in the studied
groups. Our findings showed that the reduced marker model could be used to analyse the
thoracoabdominal motion in both trained and untrained populations but performs poorly in
estimating tidal volume.
De Coninck, K., Hambly, K., Dickinson, J. and Passfield, L. (2018). Measuring the morphological characteristics of thoracolumbar fascia in ultrasound images: an inter-rater reliability study. BMC Musculoskeletal Disorders [Online] 19. Available at: http://dx.doi.org/10.1186/s12891-018-2088-5.
BACKGROUND: Chronic lower back pain is still regarded as a poorly understood multifactorial condition. Recently, the thoracolumbar fascia complex has been found to be a contributing factor. Ultrasound imaging has shown that people with chronic lower back pain demonstrate both a significant decrease in shear strain, and a 25% increase in thickness of the thoracolumbar fascia. There is sparse data on whether medical practitioners agree on the level of disorganisation in ultrasound images of thoracolumbar fascia. The purpose of this study was to establish inter-rater reliability of the ranking of architectural disorganisation of thoracolumbar fascia on a scale from ‘very disorganised’ to ‘very organised’. METHODS: An exploratory analysis was performed using a fully crossed design of inter-rater reliability. Thirty observers were recruited, consisting of 21 medical doctors, 7 physiotherapists and 2 radiologists, with an average of 13.03 ± 9.6 years of clinical experience. All 30 observers independently rated the architectural disorganisation of the thoracolumbar fascia in 30 ultrasound scans, on a Likert-type scale with rankings from 1 = very disorganised to 10 = very organised. Internal consistency was assessed using Cronbach’s alpha. Krippendorff’s alpha was used to calculate the overall inter-rater reliability. RESULTS: The Krippendorf’s alpha was .61, indicating a modest degree of agreement between observers on the different morphologies of thoracolumbar fascia.The Cronbach’s alpha (0.98), indicated that there was a high degree of consistency between observers. Experience in ultrasound image analysis did not affect constancy between observers (Cronbach’s range between experienced and inexperienced raters: 0.95 and 0.96 respectively). CONCLUSIONS: Medical practitioners agree on morphological features such as levels of organisation and disorganisation in ultrasound images of thoracolumbar fascia, regardless of experience. Further analysis by an expert panel is required to develop specific classification criteria for thoracolumbar fascia.
Dickinson, J., Amirav, I. and Hostrup, M. (2018). Nonpharmacologic Strategies to Manage Exercise-Induced Bronchoconstriction. Immunology and Allergy Clinics of North America [Online] 38:245-258. Available at: https://doi.org/10.1016/j.iac.2018.01.012.
Pharmacological management of exercise induced bronchoconstriction (EIB) is the mainstay of preventative therapy. However, there are some non-pharmacological interventions that may assist the management of EIB. In this review we will discuss these non-pharmacological interventions and how they may be applied to patients and athletes with EIB.
Jackson, A., Hull, J., Hopker, J. and Dickinson, J. (2018). Impact of detecting and treating exercise-induced bronchoconstriction in elite footballers. European Respiratory Journal Open Research [Online] 4. Available at: http://dx.doi.org/10.1183/23120541.00122-2017.
Our aim was to evaluate the prevalence of exercise-induced bronchoconstriction (EIB) in elite football players and assess subsequent impact of therapy on airway health and exercise performance. 97 male professional football players completed an airway health assessment with a eucapnic voluntary hyperpnoea (EVH) challenge to diagnose EIB. Players demonstrating a positive result (EVH+) were prescribed inhaler therapy depending on severity, including inhaled corticosteroids and inhaled short-acting β2-agonists, and underwent repeat assessment after 9 weeks of treatment. Eight players (EVH+ n=3, EVH− n=5) completed a peak oxygen uptake (V′O2peak) test at initial and follow-up assessment. Out of the 97 players, 27 (28%) demonstrated a positive EVH result. Of these, 10 had no prior history (37%) of EIB or asthma. EVH outcome was not predictable by respiratory symptoms. Seven (24%) of the 27 EVH+ players attended follow-up and demonstrated improved post-challenge spirometry (forced expiratory volume in 1 s pre-test −22.9±15.4%, post-test −9.0±1.6%; p=0.018). At follow-up V′O2peak improved by 3.4±2.9 mL·kg−1·min−1 in EVH+ players compared to 0.1±2.3 mL·kg−1·min−1 in EVH− players. Magnitude of inference analysis indicated treatment was possibly beneficial (74%) for exercise capacity.
Elite football players have a high EIB prevalence. Treatment with inhaler therapy reduces EIB severity.
Molphy, J., Dickinson, J., Chester, N., Loosemore, M. and Whyte, G. (2017). The Effect of 400 µg Inhaled Salbutamol on 3 km Time Trial Performance in a Low Humidity Environment. Journal of Sports Science and Medicine [Online]:581-588. Available at: http://www.jssm.org/hfabst.php?id=jssm-16-581.xml.
The Objectives of the study were to investigate whether 400 µg inhaled salbutamol influences 3 km running time-trial performance and lung function in eucapnic voluntary hyperpnoea positive (EVH+ve) and negative (EVH-ve) individuals. Fourteen male participants (22.4 ± 1.6yrs; 76.4 ± 8.7kg; 1.80 ± 0.07 m); (7 EVH+ve; 7 EVH-ve) were recruited following written informed consent. All participants undertook an EVH challenge to identify either EVH+ve (?FEV1>10%) or EVH-ve (?FEV1<10%). Participants performed three separate 3 km running time-trials in a low-humidity (20-25%) environment on a non-motorized treadmill, 15 minutes following inhalation of salbutamol (400 µg), placebo (non-active inhalant) or control (no inhalant), in a randomized, single-blind, repeated measures design. Forced vital capacity maneuvers were performed at baseline, 10 minutes post inhalation and post time-trial. Time to complete 3 km and lung function data were analyzed using mixed model repeated measures ANOVA. Significance was assumed at p < 0.05. All EVH+ve participants had FEV1 falls from baseline between 10-25% post-challenge. There was no difference in performance time between trial conditions in EVH+ve (1012.7 ± 129.6s; 1002.4 ± 123.1s; 1015.9 ± 113.0s) (p = 0.774) and EVH-ve (962.1 ± 99.2s; 962.0 ± 76.2s; 950.8 ± 84.9s) (p = 0.401) groups for salbutamol, placebo and control trials, respectively. Exercising heart rate was significantly higher (p = 0.05) in the salbutamol trial (183 ± 8 beats?min-1) compared to control (180 ± 9 beats?min-1) with a trend towards significance (p=0.06) in the placebo trial (179 ± 9 beats?min-1) for the pooled groups, no differences were seen between trials in groups individually. There was an increase in FEV1 in both EVH+ve (4.01 ± 0.8L; 4.26 ± 0.7L; 4.25 ± 0.5L) and EVH-ve (4.81 ± 0.4L; 5.1 ± 0.4L; 5.1 ± 0.5L) groups which was significant post-inhalation (p = 0.01; p = 0.02), but not post-time-trial (p = 0.27; p = 0.06), respectively, following salbutamol. EVH+ve participants did not demonstrate significant falls (>10% from baseline) in FEV1 following any time-trial. Administration of 400µg inhaled salbutamol does not improve 3 km time-trial performance in either mild EVH+ve or EVH–ve individuals despite significantly increased HR and FEV1.
Hull, J., Jackson, A. and Dickinson, J. (2017). Cough in Exercise and Athletes. Pulmonary Pharmacology & Therapeutics [Online] 47:49-55. Available at: http://dx.doi.org/10.1016/j.pupt.2017.04.005.
Cough is the most common respiratory symptom reported by athletes and can significantly impact on health status, ability to train and athletic performance. The presence of cough in an athlete is typically taken to indicate exercise-induced bronchoconstriction (EIB), yet in many athletes with chronic cough there is no objective evidence of airway hyper-responsiveness (AHR) or heightened airway inflammation. Moreover, cough in athletes often fails to respond to a therapeutic asthma strategy, thus further work is urgently needed to progress our understanding of the pathophysiology of exercise-associated cough in this unique population.
This article provides an overview of the current state of knowledge of exercise-associated cough in athletes. The article summarises our understanding of pathophysiological basis of cough in this context and provides a pragmatic clinical approach to this problem.
Massaroni, C., Carraro, E., Vianello, A., Miccinilli, S., Morrone, M., Levai, I., Schena, E., Saccomandi, P., Sterzi, S., Dickinson, J., Winter, S. and Silvestri, S. (2017). Optoelectronic plethysmography in clinical practice and research: a review. Respiration [Online] 93:339-354. Available at: http://dx.doi.org/10.1159/000462916.
Background: Optoelectronic plethysmography (OEP) is a non-invasive motion capture method to measure chest wall movements and estimate lung volumes. Objectives: To provide an overview of the clinical findings and research applications of OEP in the assessment of breathing mechanics across populations of healthy and diseased individuals. Methods: A bibliographic research was performed with the terms “opto-electronic plethysmography,” “optoelectronic plethysmography,” and “optoelectronic plethysmograph” in 50 digital library and bibliographic search databases resulting in the selection of 170 studies. Results: OEP has been extensively employed in studies looking at chest wall kinematics and volume changes in chest wall compartments in healthy subjects in relation to age, gender, weight, posture, and different physiological conditions. In infants, OEP has been demonstrated to be a tool to assess disease severity and the response to pharmacological interventions. In chronic obstructive pulmonary disease patients, OEP has been used to test if patients can dynamically hyperinflate or deflate their lungs during exercise. In neuromuscular patients, respiratory muscle strength and chest kinematics have been analyzed. A widespread application of OEP is in tailoring post-operative pulmonary rehabilitation as well as in monitoring volume increases and muscle contributions during exercise. Conclusions: OEP is an accurate and validated method of measuring lung volumes and chest wall movements. OEP is an appropriate alternative method to monitor and analyze respiratory patterns in children, adults, and patients with respiratory diseases. OEP may be used in the future to contribute to improvements in the therapeutic strategies for respiratory conditions.
Levai, I., Hull, J., Loosemore, M., Greenwell, J., Whyte, G. and Dickinson, J. (2016). Environmental influence on the prevalence and pattern of airway dysfunction in elite athletes. Respirology [Online] 21:1391-1396. Available at: https://doi.org/10.1111/resp.12859.
BACKGROUND AND OBJECTIVE: Elite swimming and boxing require athletes to achieve relatively high minute ventilation. The combination of a sustained high ventilation and provocative training environment may impact the susceptibility of athletes to exercise-induced bronchoconstriction (EIB). The purpose of this study was to evaluate the prevalence of EIB in elite Great British (GB) boxers and swimmers. METHODS: Boxers (n=38, mean age: 22.1 ± 3.1 years) and swimmers (n=44, mean age: 21.1 ± 2.6 years) volunteered for the study. Athletes completed an exercise-induced respiratory symptom questionnaire, baseline assessment of fraction of exhaled nitric oxide (FeNO), maximal spirometry manoeuvres and a eucapnic voluntary hyperpnoea (EVH) challenge. EIB was confirmed if forced expiratory volume in 1 s (FEV1 ) reduced by ≥10% from baseline at two time points post-EVH challenge. RESULTS: The prevalence of EIB was greater in elite swimmers (30 of 44; 68%) than in boxers (3 of 38; 8%) (P<0.001). Twenty-two out of the 33 (67%) EVH-positive athletes had no prior diagnosis of asthma/EIB. Moreover, 12% (6 of 49) of the EVH-negative athletes had a previous diagnosis of asthma/EIB. We found a correlation between FeNO and FEV1 change in lung function post-EVH challenge in swimmers (r=0.32; P=0.04) but not in boxers (r=0.24; P=0.15). CONCLUSION: The prevalence of EIB was ninefold greater in swimmers when compared with boxers. Athletes who train and compete in provocative environments at sustained high ventilation may have an increased susceptibility to EIB. It is not entirely clear whether increased susceptibility to EIB affects elite sporting performance and long-term airway health in elite athletes.
Price, O., Ansley, L., Levai, I., Molphy, J., Dickinson, J. and Hull, J. (2016). Eucapnic Voluntary Hyperpnea Testing in Asymptomatic Athletes. American Journal of Respiratory and Critical care Medicine [Online] 193:1178-1180. Available at: http://dx.doi.org/10.1164/rccm.201510-1967LE.
Hull, J., Ansley, L., Price, O., Dickinson, J. and Bonini, M. (2016). Eucapnic Voluntary Hyperpnea: Gold Standard for Diagnosing Exercise-Induced Bronchoconstriction in Athletes?. Sports Medicine [Online] 46:1083-1093. Available at: http://dx.doi.org/10.1007/s40279-016-0491-3.
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.
Hull, J., Scadding, G., Dickinson, J. and Greenwell, J. (2016). Medical Care of AQUATIC Athlete: Do Not Overlook the Upper Airway. Current sports medicine reports [Online] 15:46-46. Available at: http://dx.doi.org/10.1249/JSR.0000000000000224.
Dickinson, J., Hu, J., Chester, N., Loosemore, M. and Whyte, G. (2015). The Impact of Inhaled Salbutamol on Repeated Sprint Ability in Pre-Fatigued Soccer Players. Journal of Sports Medicine and Doping Studies [Online]. Available at: http://www.omicsonline.org/open-access/the-impact-of-inhaled-salbutamol-on-repeated-sprint-ability-in-prefatigued-soccer-players-2161-0673-1000164.pdf.
Spiteri, D., Dickinson, J., Greenwell, J. and Ingle, L. (2014). Impact of exercise-induced bronchoconstriction on athletic performance and airway health in rugby union players. International Sportsmed Journal [Online] 15:333-342. Available at: http://www.ismj.com/.
Background: There is emerging evidence that the prevalence of exercise-induced bronchospasm (EIB) is significantly under-reported in many sports. There is little known about the potential performance improvement that may exist when sports players are detected and treated for EIB. Methods: Professional rugby union players with no previous history of asthma volunteered to participate in the study. Each player performed the rugby football union (RFU) fitness test and completed a eucapnic voluntary hyperpnoea (EVH) challenge at baseline and 12 weeks later. A player with a positive EVH result was prescribed beclomethasone inhaler (200 µg; two puffs per day) for 12 weeks. Players with a negative EVH test were randomly allocated to either a placebo inhaler group or acted as controls. Results: Twenty-nine rugby union players (mean ± SD; age 22.1 ± 4.2 years; body mass 100.1 ± 6.9 kg; height 1.84 ± 0.07 m) were recruited. Seven players (24% of total) had a positive EVH challenge with a mean decrease in FEV1 of -13.6 ±3.5 % from baseline. There was no significant group difference (P=0.359)in performance improvement of the RFU fitness test between the EVH positive group (mean ?: -22.3 seconds; 8.0 ± 2.8% improvement), placebo group (mean ?: -16.5 seconds; 6.7 ± 1.6% improvement), and controls (mean ?: -12.2 seconds; 5.7 ± 3.5% improvement). Conclusion: Prevalence of EIB in professional rugby union players was 24%. A 12-week prescription of beclomethasone (200 µg) showed similar improvements in RFU fitness test performance in players diagnosed with EIB compared to players with healthy airway responsiveness.
Dickinson, J., Hu, J., Chester, N., Loosemore, M. and Whyte, G. (2014). Impact of Ethnicity, Gender, and Dehydration on the Urinary Excretion of Inhaled Salbutamol With Respect to Doping Control. Clinical Journal of Sport Medicine [Online] 24:482-489. Available at: http://dx.doi.org/10.1097/JSM.0000000000000072.
OBJECTIVE: To examine the impact of dehydration, ethnicity, and gender on urinary concentrations of salbutamol in relation to the threshold stipulated by the World Anti-Doping Agency (WADA). DESIGN: Repeated measures open-label. PARTICIPANTS: Eighteen male and 14 female athletes (9 white males, 9 white females, 2 Afro-Caribbean males, 2 Afro-Caribbean females, 6 Asian [Indian subcontinent] males, and 4 Asian females) were recruited. All participants were nonasthmatic. INTERVENTIONS: After inhalation of 800 μg or 1600 μg of salbutamol, athletes exercised in a hot controlled environment (35°C, 40% relative humidity) at a self-selected pace until a target weight loss (2% or 5%) was achieved. MAIN OUTCOME MEASURES: Urine concentration of free salbutamol. RESULTS: After inhalation of 1600 μg salbutamol, 20 participants presented with a urine salbutamol concentrations above the current WADA limit (1000 ng/mL) and decision limit (1200 ng/mL) resulting in an adverse analytical finding. There were no differences according to gender or ethnic origin. CONCLUSIONS: Dehydration equivalent to a body mass loss greater than 2% concomitant to the acute inhalation of 1600 μg of salbutamol may result in a urine concentration above the current WADA limit and decision limit leading to a positive test finding independent of gender or ethnic origin. CLINICAL RELEVANCE: Asthmatic athletes using salbutamol should receive clear dosing advise and education to minimize the risk of inhaling doses of salbutamol that may produce urine concentrations of salbutamol above 1200 ng/mL.
Allen, H., Hull, J., Backhouse, S., Dickinson, J., De Carné, T., Dimitriou, L. and Price, O. (2019). The role of fractional exhaled nitric oxide in the assessment of athletes reporting exertional dyspnoea. In: European Academy of Allergy and Clinical Immunology (EAACI) Congress. Wiley. Available at: https://doi.org/10.1111/all.13959.
Background: Exercise-induced bronchoconstriction (EIB) is a common cause of breathing difficulty in athletes. Fractional exhaled nitric oxide (FeNO) is an indirect marker of airway inflammation, recommended for the assessment and management of asthma; however, the role of FeNO in detecting and monitoring EIB has yet to be fully established. The aim of this study was therefore to evaluate the predictive value of FeNO to confirm or refute EIB in athletes presenting with exertional dyspnoea. Method: Seventy athletes (male: n = 45) (age: 35 ± 11 years) reporting respiratory symptoms (i.e. wheeze, cough and dyspnoea) during exercise attended the laboratory on a single occasion. All athletes performed resting FeNO and spirometry pre-and-post a eucapnic voluntary hyperpnoea challenge (EVH) in accordance with international guidelines. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for established FeNO thresholds: (intermediate [≥25ppb] and high [>50ppb]) and evaluated against objective evidence of EIB: (EVH diagnostic cut-off [-10% ΔFEV1 at two consecutive time-points] and [-15% ΔFEV1 at one time-point]). The diagnostic accuracy of FeNO was calculated using receiver operating characteristics area under the curve (ROC-AUC). Results: All had normal resting lung function (>80% FEV1 pred). The prevalence of EIB was 33% (-10% ΔFEV1) and 23% (-15% ΔFEV1) (median (IQR) ΔFEV1 = -7% (10.02)). FeNO values ≥25ppb and >50ppb were observed in 49% and 23% of the cohort, respectively. ROC-AUC for FeNO was 75% (-10% ΔFEV1) and 86% (-15% ΔFEV1). Sensitivity, specificity, PPV and NPV are presented in Table 1. Conclusion: Our findings indicate that FeNO >50ppb provides good specificity for a positive EVH test; however, should not replace indirect bronchoprovocation for diagnostic purposes. The high proportion of athletes reporting breathing difficulty in the absence of EIB highlights the requirement to consider alternative causes of exertional dyspnoea during clinical work-up.
Smyth, C., Dickinson, J. and Winter, S. (2019). OEP derived thoracoabdominal movement parameters significantly distinguish between rest, various exercise intensities, and recovery. In: International Society of Biomechanics and American Society of Biomechanics.
Smyth, C., Winter, S. and Dickinson, J. (2018). Validation of breathing frequency algorithms in impedance pneumography. In: European Respiratory Society International Congress.
Gowers, W., Jackson, A., Hull, J., Hopker, J. and Dickinson, J. (2018). Indirect airway challenges and asthma related conditions in healthy active individuals. In: European Respiratory Society International Congress.
Merlini, M., Beato, M., Marcora, S. and Dickinson, J. (2017). The effect of 1600 ng salbutamol administration on 30m sprint performance in football players. In: 22nd Annual Congress of European College of Sport Science.
Levai, I., Massaroni, C., Hull, J., Whyte, G., Silvestri, S. and Dickinson, J. (2017). Optoelectronic plethysmography characterises thoracic excursion in the evaluation of dysfunctional breathing. In: American College of Sports Medicine Annual Conference (May 2017). Lippincott, Williams & Wilkins. Available at: https://doi.org/10.1249/01.mss.0000518720.81444.01.
Levai, I., Massaroni, C., Hull, J., Whyte, G., Silvestri, S., Winter, S. and Dickinson, J. (2017). Optoelectronic plethysmography (OEP) in the assessment of dysfunctional breathing (DB) in athletes. In: ERS Annual Congress 2016. European Respiratory Society: ERJ. Available at: http://dx.doi.org/10.1183/13993003.congress-2016.PA2248.
Introduction: Muscle recruitment and motor pattern are important not only to preserve intra-abdominal pressure but also to optimise biomechanical functions. A deviation away from the optimal trunk lumbo-pelvic recruitment pattern can affect the pressure, the ventilatory volumes, the stability and ultimately the work of breathing.
Aims and objectives: The aim of the study was to investigate the effect of different postural positions on the respiratory system using optoelectronic plethysmography (OEP) and a breath-by-breath (BbB) analyser.
Methods: Five healthy male athletes (Mean +/- SD age: 31.2±5.6 yrs.) completed the study protocol. They performed a 10-minute submaximal exercise test in two conditions (with hunched shoulders and with normal shoulder position) while undergoing simultaneous OEP and BbB data collection. Tidal volume (VT), breathing frequency (BF) and minute ventilation (VE) were assessed by the BbB analyser and data was gathered on the chest wall volume (CW) and the compartmental volumes of the rib cage (RC) and the abdomen (AB) by OEP.
Results: With the BbB analyser we detected a difference in tidal volume (VT) between the 'normal' and 'hunched' positions (2.94±0.84 l vs. 2.69±0.79 l; p=0.05) in the last stage of the 10-minute cycling test. This difference was detected also by the OEP system when CW contributions in the two conditions were compared (3.45±0.82 vs. 2.97±0.72; p=0.02). The other values remained unchanged.
Conclusions: Respiratory parameters may be affected during exercise by the postural positions of the shoulders leading to impaired chest wall movement and decreased tidal volumes. OEP may be a useful tool to assess altered parameters associated with DB.
Levai, I., Hull, J., Whyte, G. and Dickinson, J. (2017). Posture during exercise effects breathing pattern and reports of dyspnoea. In: American College of Sports Medicine Annual Conference (May 2017).
Hull, J., Jackson, A., Hopker, J., Greenwell, J. and Dickinson, J. (2017). Maximizing Respiratory Health in Elite Swimmers – A systematic approach to optimize total airway health. In: American College of Sports Medicine Annual Conference (May 2017). Available at: https://journals.lww.com/acsm-msse/Fulltext/2017/05001/Maximizing_Respiratory_Health_In_Elite_Swimmers__.933.aspx.
Levai, I., Hull, J., Whyte, G. and Dickinson, J. (2016). Relationship between dysfunctional breathing and exercise-induced bronchoconstriction in athletic populations. In: ERS Annual Congress 2016. European Respiratory Society: ERJ. Available at: http://dx.doi.org/10.1183/13993003.congress-2016.PA1585.
Introduction: Dysfunctional breathing (DB) may mimic and/or coexist with exercise-induced bronchoconstriction (EIB) and tools to aid diagnosis precision are needed.
Aims and objectives: The aim of this study was to evaluate the relationship between the score of a commonly used questionnaire to detect DB, namely the Nijmegen questionnaire (NQ) and objective evidence of EIB, from indirect bronchoprovocation testing.
Methods: One hundred and four athletes (Mean +/- SD age: 23.1±4.4 yrs.; n=79 (76%) males; n=62 (59.6%) elite athletes); underwent an eucapnic voluntary hyperpnoea (EVH) challenge and completed the NQ. A cut-off value of ?10% in FEV1 fall from baseline in EVH post challenge and a score of ? 23 in the NQ were considered positive results.
Results: Fifty-two (50%) participants had a positive EVH challenge and 17 (16.4%) had a positive NQ score. We found no relationship between mean NQ scores and the maximal fall in FEV1 post-EVH challenge (r= -0.09; p=0.37). The sensitivity, specificity, positive predicted value (PPV) and negative predicted value (NPV) of a positive NQ score predicting EIB were 15.38%, 82.69%, 47.06% and 49.43%, respectively.
Conclusions: We found a poor relationship between NQ score and the outcome of the EVH challenge. Dysfunctional breathing may be best assessed using different objective measures than those used for diagnosis of obstructive airway disease.
Levai, I., Hull, J., Whyte, G. and Dickinson, J. (2016). Structural validity of the Nijmegen questionnaire in physically active young adults. In: ERS Annual Congress 2016. European Respiratory Society: ERJ. Available at: http://dx.doi.org/10.1183/13993003.congress-2016.PA2199.
Introduction: Respiratory symptoms are frequently reported by athletes of all abilities and can significantly impact exercise performance and health. The Nijmegen Questionnaire (NQ) has been previously used to identify dysfunctional breathing across several populations, but not among athletes.
Aims and objectives: We aimed to investigate the factor structure of the NQ in a population of recreational athletes and propose a shorter version of the instrument.
Methods: The NQ (n=428) was examined for construct validity through principal components analysis (PCA). Factorability was tested via KMO index and Bartlett's test of sphericity.
Results: Primary evaluation of the data revealed a 'complex structure', therefore four items were excluded from further analysis. PCA revealed three components which we have labelled as in Table 1.
Massaroni, C., Levai, I., Dickinson, J., Winter, S. and Silvestri, S. (2016). Breathing Analysis During Exercise: Comparison Between Optoelectronic System and Breath-By Breath Analyzer. In: 22nd Congress of the European Society of Biomechanics. Available at: https://esbiomech.org/conference/index.php/congress/lyon2016/.
Jackson, A., Hopker, J. and Dickinson, J. (2016). Exercise-Induced Bronchoconstriction: Impact on Health and Performance. In: XXV International Conference on Sports Rehabilitation and Traumatology. Football Medicine Strategies. Return to Play. Available at: http://www.footballmedicinestrategies.com/all/doc/upl/s1/RTP%202016%20-%20Abstract%20Book.pdf.
Merlini, M., Whyte, G., Chester, N., Loosemore, M., Marcora, S. and Dickinson, J. (2016). The Long-Term Ergogenic Effect of Long Acting ?2-Agonists. In: 21st Annual Congress of European College of Sport Science.
Background: The WADA List of Banned Substances and Methods stipulates that athletes can use up to 54 µg inhaled Formoterol and inhaled Salmeterol as directed by the manufacturer. It is unknown whether large daily therapeutic doses of Formoterol and Salmeterol can improve sprint and strength performance.
Purpose: To investigate the impact of inhaling 100 µg of Salmeterol (SAL) or 12 µg of Formoterol (FOR) twice daily over a 5 week period on sprint, strength and power performance.
Methods: In a randomised single blind study 24 male and 15 female non-asthmatic and active participants were recruited (mean ± SD; Males age 28.0 ± 5.5 years; weight 72.1 ± 10.5 Kg; height 164.7 ± 7.1 cm; Females age 24.1 ± 4.1 years; weight 65.4 ± 9.5 Kg; height 168.0 ± 4.3 cm). Participants completed three standardised whole body strength and power training sessions per week for five weeks. All the training sessions were supervised by a personal trainer who recorded work performed in each session. During the five week training period participants were assigned to either SAL, FOR or a placebo (PLA) group. Participants took their inhaler twice per day as instructed. Participants completed assessments of sprint, strength and power at week 0 and after 5 weeks of strength and power training. The assessments included 30 m sprint, vertical jump, 1 RM bench press, 1 RM leg press, peak torque flexion and extension, anthropometric evaluation and Rest-Q questionnaires. Mixed Model Repeated Measures ANOVA were performed to investigate the changes in the sprint, strength and power assessments between groups over the course of the 5 week training session.
Results: 30 m Sprint time was significantly lower in FOR group (– 0.29 ± 0.11 s; p=0.049) and SAL (– 0.35 ± 0.05 s; p=0.04) when compared with compared with Placebo (+0.01 ± 0.11 s; P=0.000). No significant change was found in 1RM Leg, Squat and Bench Press or during Isokinetic evaluation performed at 60° range in flex/ext movement. Jump performance as well as anthropometric measures didn’t differ between groups.
Discussion: The significant changes in FOR and SAL 30m sprint time when compared to PLA suggest the long term use of inhaled ?2-agonnists may provide ergogenic advantage. This finding suggests a review of the use of inhaled doses of FOR and SAL by athletes in training and official competition may be necessary.
De Coninck, K., Hambly, K., Passfield, L., Dickinson, J. and Muthumayandi, K. (2015). Inter-observer agreement of thoracolumbar fascia morphology: an exploratory analysis of ultrasound images. In: Fourth International Fascia Research Congress. Elsevier, pp. 668-669. Available at: https://doi.org/10.1016/j.jbmt.2015.07.005.
BACKGROUND: Ultrasound imaging (USI) has been shown to be a valid method to investigate the morphology of the thoracolumbar fascia (TLF) . A USI-based study has demonstrated that the TLF of subjects with chronic lower back pain (LBP) is on average 25% thicker and more disorganised compared to a control group . The aim of this study is to explore inter-observer agreement between a range of clinicians on (dis)organisation of TLF in ultrasound images. There are currently no validated methods for the evaluation of USI of TLF.
METHODS: Design: an exploratory analysis using a fully crossed design of inter-observer agreement. This study was approved by the University of Kent’s School of Sport and Exercise Sciences Research and Ethics Committee (Prop. 163 – 2013). Participants: Thirty observers consisting of 21 (70%) Medical Doctors, 7 (23%) physiotherapists and 2 (6%) radiologists, with a combined total average of 13 years of clinical experience (± SD 9.4). 57% had no experience in USI, 36% had experience ranging from monthly to daily evaluations of USI, no observers had experience in evaluating USI of TLF. Protocol: A sub-set of thirty ultrasound scans of TLF were randomly selected from a data set of 308 scans of subjects with and without LBP (from a larger study conducted by the first author). All scans were anonymised and displayed on a desktop computer, or projected on a screen. All observers viewed and rated each of the 30 scans independently on a Likert-type scale from 1(very disorganised) to 10 (very organised). Inter-observer agreement was assessed using a two-way mixed, consistency, average measures intra-class correlation (ICC), the Cronbach’s Alpha, to assess consistency among observers. The Krippendorff’s Alpha (Kalpha)  reliability estimate was used to assess agreement.
RESULTS: The resulting ICC was in the excellent range, ICC = 0.98, indicating that observers had a high degree of consistency, suggesting that (dis)organisation was rated similarly across observers. Observers without USI experience scored an ICC = 0.96, observers with USI experience scored an ICC = 0.95, again both in the excellent range. In this small cohort, experience in USI does not appear to impact on consistency. The Krippendorff’s ordinal alpha ? was .621, indicating a modest degree of agreement.
CONCLUSIONS: The high ICC and modest Kalpha suggest that a minimal amount of measurement error was introduced by the independent observers, and therefore statistical power for subsequent analyses is not substantially reduced. This will allow for further analysis of USI images of TLF in terms of morphology and classification. This could ultimately, lead to a meaningful evaluation of treatments of TLF.
Merlini, M., Whyte, G., Chester, N., Loosemore, M., Marcora, S. and Dickinson, J. (2015). Long-term β2-agonists administration increases sprint and strength performance in non-asthmatic. In: 20th Annual Congress of European College of Sport Science.
De Coninck, K., Hambly, K., Passfield, L., Dickinson, J. and Muthumayandi, K. (2015). Inter-observer agreement of thoracolumbar fascia morphology: An exploratory analysis of ultrasound images. In: pp. 668-669.
Levai, I., Hull, J., Whyte, G. and Dickinson, J. (2015). Detection of exercise-respiratory symptoms in a young adult population. In: RSM Exercise Medicine Meeting.