DIFFERENT APPROACHES TO IDENTIFYING DYSFUNCTIONAL BREATHING (DB) IN ATHLETES

Perceived exertional dyspnoea is reported to be the most common symptom among physically active individuals of all abilities and ages and/or performance in high level athletes, potentially impacting on performance and limiting enjoyment of sporting activities. Identifying the causes of the perceived symptoms requires careful assessment with a wide range of factors potentially contributing to the reported respiratory issues. The purpose of this thesis was to investigate different assessment approaches in the identification of breathing dysfunction in exercising adults. Elite swimming and boxing require athletes to achieve relatively high minute ventilation. In Chapter 4 (Study 1 of this thesis), thirty-eight elite boxers and 44 elite swimmers completed a thorough respiratory assessment that revealed a nine-fold greater prevalence of exercise-induced bronchoconstriction in swimmers when compared with boxers. These results suggested that the combination of a sustained high ventilation and provocative training environment may impact the susceptibility of athletes to this condition. Dysfunctional breathing may mimic and/or co-exist with exercise-induced bronchoconstriction. The use of specific questionnaires may improve the identification of this condition in athletes. In Chapter 5 (Study 2 of this thesis), 9% of the 428 healthy, physically active young adults who completed the Nijmegen Questionnaire had a score ? 23, suggestive of a dysfunctional breathing status. A separate cohort of 104 athletes underwent an indirect bronchoprovocation challenge and completed the Nijmegen questionnaire. The sensitivity, specificity, positive and negative predicted values suggested that the Nijmegen score was a poor predictor of a positive bronchoprovocation challenge in athletes and therefore is not suitable to detect dysfunctional breathing in athletes. The posture an athlete holds during exercise may alter breathing pattern and increase reported exercise induced respiratory symptoms. In order to investigate whether respiratory parameters are affected by different postural positions, in Chapter 6 (Study 3 of this thesis), 15 healthy male athletes performed a 10-minute, high intensity cycling test with normal shoulder position and with hunched shoulders. Results of this study showed that cycling with hunched shoulders at high intensities over a prolonged period leads to an increase in perceived dyspnoea and suggested that posture may contribute to reports of respiratory symptoms during exercise in the absence of cardio-pulmonary disease. With the aim of investigating the effect of different postural positions on the ventilatory excursion, in Chapter 7 (Study 4 of this thesis), 15 healthy male athletes performed baseline spirometric measurements and 10-minutes cycling challenges with normal shoulder position and with hunched shoulders, while undergoing simultaneous data collection with optoelectronic plethysmography. The findings of this study suggested that respiratory excursion and lung volume compartmentalisation at both rest and during high intensity exercise are affected by the position of the shoulders. In conclusion, athletes who train and compete in provocative environments at a sustained high ventilation have an increased susceptibility to airway dysfunction. No existing questionnaire is sensitive enough to identify dysfunctional breathing and differentiate it from other respiratory conditions, such as exercise-induced bronchoconstriction. Exercising for a prolonged period at high intensities with hunched shoulders triggers increased abdominal contribution to vital capacity and a subsequent increase in perception of breathing sensation without a significant effect on physiological markers of respiratory function. Further investigations should be undertaken in order to develop a new questionnaire that is more suitable for an athletic population and has higher accuracy in identifying symptoms associated with exercise induced breathing impairment. Precise detection of distortions between compartmental contributions in exercising individuals may play an important role in the differential diagnosis of dysfunctional breathing

Optoelectronic plethysmography in clinical practice and research: a review

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

Singing for Better Breathing: Findings from the Lambeth & Southwark Singing & COPD Project

Over the last eight years there has been a growth of interest in the potential value of participation in singing groups for people with chronic obstructive pulmonary disease (CODP) and other respiratory illnesses. This is shown by the increasing number of singing for breathing groups established across the UK over this period. The British Lung Foundation have taken a leading role in promoting this activity through their ‘Singing for Lung Health’ programme. A limited number of small-scale research studies have assessed the benefits of singing for people with COPD and other lung conditions. These include three randomised controlled trials, one in Brazil, and two conducted at the Royal Brompton Hospital in London. Further studies have been carried out in Canada, New Zealand, the UK and the USA. There is limited evidence that singing improves lung function and exercise capacity, but qualitative feedback from participants has been highly positive. Testimonies point to singing having substantial subjective benefits for physical, psychological and social wellbeing, and in enabling people with COPD to better manage their lung condition. The current study in Lambeth and Southwark, South London, was based on earlier research conducted in East Kent, UK. Morrison et al. (2013) established and evaluated a network of six community singing groups for people with COPD which ran over the course of ten months. Seventy-two people with COPD were followed up over this time and assessed using validated questionnaires, with St. George’s Respiratory Questionnaire (SGRQ) as the primary outcome measure. Spirometry was also used to assess lung function. Significant improvements were found on the total and impact scores from the SGRQ, and participants also improved in their lung function

Relationship between dysfunctional breathing and exercise-induced bronchoconstriction in athletic populations

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

Structural validity of the Nijmegen questionnaire in physically active young adults

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

T6?Impact Of Environmental Differences In The Prevalence Of Airway Dysfunction In Elite Athletes: Gb Boxing Vs. Gb Swimming

Objectives Exercising in a provocative environment (e.g. indoor swimming pool) at sustained high minute ventilation rates may increase the prevalence of airway dysfunction in athletic populations. The purpose of the study was to evaluate the impact of environmental differences in the prevalence of airway dysfunction in two cohorts of elite GB athletes. Methods Airway dysfunction was evaluated in the GB boxing (n = 39, Mean (SD) age: 22.0 (3.2) yrs.) and swimming squads (n = 33, Mean (SD) age: 21.0 (3.0) yrs.). All participants completed a Eucapnic Voluntary Hyperpnoea (EVH) challenge test, an indirect bronchoprovocation test, to characterise airway dysfunction (defined as abnormal if >10% fall in FEV1 post­­-challenge). Fraction of exhaled Nitric Oxide (FeNO) was measured and participants completed a symptom and medication questionnaire. Results The prevalence of airway dysfunction was greater in elite swimmers (70%) than boxers (8%) (p < 0.001) (Figure 1). The EVH assessment process revealed missed and incorrect diagnosis of airway dysfunction; specifically 65% (17 of 26) of those with airway dysfunction had no prior diagnosis of asthma or exercise induced bronchoconstriction. Moreover, a prior diagnosis of asthma was not supported by testing in 9% (4 of 46) of the athletes. These athletes were prescribed one or a combination of short-acting ?2-agonists, long-acting ?2-agonists and inhaled corticosteroids. Neither symptoms nor baseline lung function were predictive of a positive EVH-challenge in swimmers. No correlation between change in lung function or airway dysfunction and FeNO value. Conclusions The prevalence of airway dysfunction was nine fold greater in elite swimmers when compared with boxers. This finding emphasises the high proportion of EVH-positive elite swimmers and the importance of strategies needed to ensure their respiratory health is optimised. These results also suggest that airway dysfunction is not only related to intensity and frequency of exertional hyperpnoea but also environmental conditions