Use of the Refractory Period in the Treatment of Exercise Induced Bronchoconstictions in a Collegiat

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Use of the Refractory Period in the Treatment of
Exercise- Induced Bronchoconstictions in a
Collegiate Football Player A Case Study

• Brian G Pietrosimone, M.Ed, ATC
• John MacKnight, MD
• Ethan Saliba, PhD, PT,ATC,SCS
• Jay Hertel, PhD, ATC

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Asthma

• Exercise triggers asthma in 50 -90 of known
  Asthmatics (Parsons et al., Freed et al.)
• 10 of non asthmatics report symptoms of
  asthma during exercise (Parsons et al.)
• Wheezing
• Coughing
• Tightness in chest
• Inability to catch ones breath
• Increased mucus production

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Pathogenesis of EIB

• The pathogenesis behind exercise induced
  bronchospasm is not fully understood (Tan et al.
  Chang- Yeung)
• Different Theories
• Dehydration of mucosal lining
• Bronchial mucosal hyperemia

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Dehydration of Mucosal Lining

• Cold, dry air causes dehydration of the mucus
  membrane
• Water loss causes an increase in osmotic pressure
• Mast Cell degranulation leads to inflammatory
  mediator release
• (Parsons Mastronarde, Tan, Maler)

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Hyperemia

• Re- warming in the lungs causes distal airways to
  increase blood flow
• Increased hydrostatic pressure in bronchial
  vasculature
• Increased airway edema
• (Parsons Mastronarde, Tan, Maler)

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History

• Setting
• ACC, NCAA Division 1 Football Program
• Climate Zone 3
• Athlete Demographics
• 18 year old
• Male
• Single
• Caucasian
• Height 6 2
• Weight 258 pounds
• Position Defensive Line
• Hometown in Climate Zone 3

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Past Asthma History

• Health history form Indicated past history of
  asthma
• Exercise was a stimulus
• No other health problems, or family problems
• Prescribed prior to enrolling at the University
• Albuterol MDI prn- short-acting bronchodilator
• Salmeterol (Serevent) MDI - long-acting
  bronchodilator
• Fluticasone propionate (Flovent) MDI- inhaled
  corticosteroid

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Differential Diagnosis

• Exercise Induced Bronchospasm
• Extrinsic Asthma
• Chronic Bronchitis
• Cardiomyopathy

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FEV1

• Spirometry measurements reported a decrease of
  19 in FEV1 - confirming the diagnosis of EIB
  (Tan and Spector)
• FEV1 (Pretest FEV1 - Post test FEV1) x100
• Pretest FEV1
• No significant findings on Echocardiogram

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Pattern

• Team Physician noticed pattern

2 h
4 h
6- 10 m
Real Time
20-25 m
3h
3rd
4th
1st
2nd
Game Time
Unable to participate
Refractory Period
Able to participate
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Refractory Period

• The refractory period is the time in which the
  athlete remained asymptomatic after the first
  bout of symptoms
• Refractory period occurs in 40 to 50 of
  asthmatics (Milgrom Taussig )

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Refractory Period

• Theory suggests that a depletion in inflammatory
  mediators occurs with an initial bronchospasm
• (Freed Chang- Yeung et al.)
• Subsequent exercise results in no additional
  mediator release
• The refractory period last for 2 to 4 hours after
  the first bout of EIA (Ben- Dov et al. Wilson
  et al.)

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Treatment

• 75 minutes prior to game time under the
  supervision of the Team Physician
• 4 x 50 yard sprints at a moderate intensity
• Series of 5, 10 and 20 yard shuttle runs
• 30 second rest was taken between each shuttle run
  in order to determine if the athlete had provoked
  sufficient bronchospasm to allow for a refractory
  period.

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Treatment

• Desired response was a bout of EIB large enough
  to provoke a subsequent refractory period
• Athlete response
• Wheezing
• Coughing
• Tightness in chest
• Sputum production

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Treatment

• After team physician and athlete agreed that
  desired response had been reached
• Consciously slowed breathing rate
• Albuterol (2 puffs)
• 15-20 minute cool down time prior to team warm up

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Treatment Effect
4.5 h
6-10 m
1.5 h
2.5 h
3.25- 3.5 h
75 min
3rd
Onset of EIB
Pre- game
1st
2nd
4th
Able to play asthma free
EIB
Critical area Ability for bronchospasms to return
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Effectiveness of Treatment

• Effectiveness was greatly reliant on the ability
  of physician and athlete to adequately induce the
  initial bronchospasm
• During the Senior year
• 72 of the games asthma free (8/11)
• 2/3 bouts of EIB occurred in the second half
• Rare additional Albuterol use with good effect

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Uniqueness

• The refractory period is a well documented
  phenomenon
• It has not been documented as a treatment in the
  athletic population
• This treatment worked consistently well and
  minimized the use of medication

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Limitations with this Treatment

• Time frame does not allow for treatment prior to
  practices
• Many trials are needed to accurately predict
  refractoriness

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Implications for Future Research

• Can the refractory period be used routinely to
  effectively treat athletes?
• Mechanisms behind the refractory period
• Does the refractory period decrease EIB in
  athletes more effectively than medications?

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What do I do with this Information?

• Possible treatment strategy
• Diagnosed athlete with breakthrough EIB
• Rescue therapy in place
• Provides comfort in return to play decisions for
  ATC and sports medicine team

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Conclusion

• The timing of the refractory period can be
  manipulated to coincide with the competition,
  preventing an exercise- induced bronchospasm
  during play.

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Questions
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References

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