Perhaps the demon to rival swimmer’s shoulder around the pool deck is asthma. Asthma can present an onslaught of debilitating symptoms, but is often used as a catchall diagnosis (much like swimmer’s shoulder) to describe a vast range of conditions. Rhinitis and various allergies carry similar symptoms, but our main focus in this post will be on asthma itself. Although greats such as Mark Spitz, Tom Dolan, Kurt Grote and Amy Van Dyken (among others) have successfully battled asthma to thrive on the Olympic stage, asthma has gotten the best of many swimmers and driven them out of the sport prematurely.
Here’s a glance at some of the research linking competitive swimming to asthma:
- Bougault (2012) found that long-term, intense swim training in indoor chlorinated pools resulted in airway changes similar to non-swimmers with mild asthma, but with higher mucin expression. Increases in mucin expression were independent of airway hyperresponsiveness. Although changes occurred as a result of long term training, the study did not reach the issue of their permanence.
- In a sample of elite swimmers, Moreira (2011) found similar levels of vascular permeability (a form of airway damage) in the swimmers compared to non-swimmers, but vascular permeability was not dependent on airway hyperresponsiveness or inflammation.
- Stadelman (2011) found high levels of bronchial responsiveness in elite swimmers. 83% presented with respiratory symptoms and 65% had positive provocation test.
- Helenius (2002) conducted a five year prospective study on a group of highly trained swimmers. Of the swimmers who still swimming at both the beginning and end of study, there was a 31% asthma rate during the pretest and 44% rate five years later. Asthma reversed in swimmers who retired during the study period and returned for post-testing.
As noted previously, the data linking competitive aquatics to asthma is hardly unanimous. Sidiropoulou (2009) found that water polo players had LOWER rates of exercise induced asthma than football (aka, soccer) and basketball players of similar age. More recently, NM (2012) found no evidence of increased eiosinophilic airway inflammation in aquatic athletes compared to non-aquatic athletes.
Despite the evidence linking asthma to competitive swimming, many of us know swimmers who have all the symptoms but somehow pass the battery of tests administered in the medical clinic, especially when swimmers (or any aerobic athletes for that matter) are graded against general population norms. Being told “there’s nothing wrong you” when symptoms persist can be equally as vexing as a positive test for asthma. In a sample of Brazilian male competitive swimmers age 6-14, 32.7% showed spirometric alterations. However, in the same sample, 31.2% of those with symptoms received no treatment (Fiks 2009). These athletes often enter a frustrating cycle in which treatments, medications, and other interventions don’t work, leaving them frustrated and possibly quitting.
What can you do with Asthma?
Now, I’m a coach…not a medical doctor. Asthma is a serious medical condition that is sometimes treated by powerful steroidal medications. Always tread with caution in this area. That said, because there are definite links between asthma and several topics squarely in the coaching scope-of-practice (posture, breathing patterns, psychology, environment), coaches can do several things to become part of a solution, especially when a solution appears elusive. There’s no definite evidence of causation, but there are tangible signs of correlation that we would be remiss to ignore. Fortunately, these areas all involve aspects of health and performance that we should address as coaches anyway. It’s a true chicken-or-the-egg scenario…is the classic swimmer’s posture an antecedent to the pulmonary symptoms, or is it a byproduct of the pulmonary symptoms? Does mental stress predispose one to asthmatic symptoms or does asthma cause psychological distress?
All of the above characteristics and symptoms are hallmarks of common imbalances in swimmers, but also of faulty breathing patterns, which we have covered thoroughly here in recent months. We may hypothesize that the more functional your breathing patterns are, the more of a buffer you might have against respiratory stress. Psychology is also related to both breathing patterns and asthma: Ritz (2011) found that after a period of induced psychosocial stress, asthma sufferers exhibited expiratory lengthening and greater tidal volume variability compared to non-asthmatics.
Environment is another variable to be considered, but there is scant evidence that alternatives to chlorine such as saltwater or bromine would be an improvement. The issue simply has not been studied with the same depth as with chlorine. Since coaches have to fight for lane space in many places, getting pools to redo their entire filtration system to accommodate more intense training is a stretch, though subjectively I think we’d all take the outdoor aquatic paradise of Palo Alto or Irvine compared to a six lane, five foot deep chlorine bathtub enclosed by a protective bubble half the year.
Summary onAsthma and Swimming
Consider all factors to improve respiration proactively in healthy swimmers and to aid those struggling with asthmatic symptoms. Although breathing it is not a common part of the athletic screening process, the links between asthma with posture, breathing, and psychology are reasons that breathing patterns should be addressed in all athletes, if for no other reason than to rule out possible contributing factors. Coaches can’t treat asthma, but we can address related areas that can improve both health and performance. In terms of environment, evidence on the role of chlorine is mixed, but suggests it can exacerbate symptoms at the competitive level. Research on the effects of salt water and bromine pools remains scant and would be helpful to gain more answers on how to improve respiratory and pulmonary health in swimmers.
- Bougault V, Loubaki L, Joubert P, Turmel J, Couture C, Laviolette M, Chakir J, Boulet LP. J Allergy Clin Immunol. Airway remodeling and inflammation in competitive swimmers training in indoor chlorinated swimming pools. 2012 Feb;129(2):351-358.e1. Epub 2011 Dec 22.
- Ferrari M, Schenk K, Mantovani W, Papadopoulou C, Posenato C, Ferrari P, Poli A, Tardivo S. Attendance at chlorinated indoor pools and risk of asthma in adult recreational swimmers. J Sci Med Sport. 2011 May;14(3):184-9. Epub 2011 Jan 22.
- Font-Ribera L, Villanueva CM, Nieuwenhuijsen MJ, Zock JP, Kogevinas M, Henderson. Swimming pool attendance, asthma, allergies, and lung function in the Avon Longitudinal Study of Parents and Children cohort. J.Am J Respir Crit Care Med. 2011 Mar 1;183(5):582-8. Epub 2010 Oct 1.
- Stadelmann K, Stensrud T, Carlsen KH. Respiratory symptoms and bronchial responsiveness in competitive swimmers. Med Sci Sports Exerc. 2011 Mar;43(3):375-81.
- Moreira A, Palmares C, Lopes C, Delgado L. Airway vascular damage in elite swimmers. Respir Med. 2011 Nov;105(11):1761-5. Epub 2011 Jun 12.
- Helenius I, Rytilä P, Sarna S, Lumme A, Helenius M, Remes V, et al. Effect of continuing or finishing high-level sports on airway inflammation, bronchial hyperresponsiveness, and asthma: a 5-year prospective follow-up study of 42 highly trained swimmers. J Allergy Clin Immunol. 2002;109:962-8.
- Päivinen MK, Keskinen KL, Tikkanen HO. Swimming and asthma: factors underlying respiratory symptoms in competitive swimmers. Clin Respir J. 2010 Apr;4(2):97-103.
- Lunardi AC, Marques da Silva CC, Rodrigues Mendes FA, Marques AP, Stelmach R, Fernandes Carvalho CR Musculoskeletal dysfunction and pain in adults with asthma. J Asthma. 2011 Feb;48(1):105-10. Epub 2010 Dec 29.
- Chaves TC, de Andrade e Silva TS, Monteiro SA, Watanabe PC, Oliveira AS, Grossi DB. Craniocervical posture and hyoid bone position in children with mild and moderate asthma and mouth breathing. Int J Pediatr Otorhinolaryngol. 2010 Sep;74(9):1021-7. Epub 2010 Jun 20.
- Ritz T, Simon E, Trueba AF. Stress-induced respiratory pattern changes in asthma.Psychosom Med. 2011 Jul-Aug;73(6):514-21. Epub 2011 Jun 28.
- Fiks IN, Santos LC, Antunes T, Gonçalves RC, Carvalho CR, Carvalho CR . Incidence of asthma symptoms and decreased pulmonary function in young amateur swimmers. J Bras Pneumol. 2009 Mar;35(3):206-12.
- Sidiropoulou MP, Kokaridas DG, Giagazoglou PF, Karadonas MI, Fotiadou EG. Incidence of Exercise Induced Asthma in Adolescent Athletes Under Different Training and Environmental Conditions. J Strength Cond Res. 2011 Sep 9. [Epub ahead of print]
By Allan Phillips. Allan and his wife Katherine are heavily involved in the strength and conditioning community, for more information refer to Pike Athletics.