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

1. 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

2. 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 one’s breath • Increased mucus production

3. 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

4. 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)

5. 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)

6. 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

7. 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

9. Differential Diagnosis • Exercise Induced Bronchospasm • Extrinsic Asthma • Chronic Bronchitis • Cardiomyopathy

10. 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

11. Pattern • Team Physician noticed pattern 2 h 4 h Real Time 6- 10 m 20-25 m 3h 3rd 4th 1st 2nd Game Time Unable to participate Refractory Period Able to participate

12. 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 )

13. 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.)

14. 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.

15. 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

16. 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

17. 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

18. 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

19. 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

20. Limitations with this Treatment • Time frame does not allow for treatment prior to practices • Many trials are needed to accurately predict refractoriness

21. 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?

22. 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

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

24. Questions

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