Anti-doping Policy, Therapeutic Use Exemption and Medication Use in Athletes with Asthma: A Narrative Review and Critical Appraisal of Current Regulations

Barriers and enablers in doping, anti-doping, and clean sport: A qualitative meta-synthesis informed by the theoretical domains framework and COM-B model

To protect the integrity of sport, and the health of athletes, global anti-doping programmes seek to prevent doping, and elicit anti-doping and clean sport behaviours, through education, deterrence, detection, enforcement, and rules. To guide programme development, this meta-synthesis of qualitative research applied a behavioural science framework to identify barriers and enablers to doping, anti-doping, and clean sport. A systematic search of electronic databases up to May 2022, followed by critical appraisal, resulted in 73 included articles. Fifty-two articles reported the athlete perspective, thirteen included athletes, athlete support personnel (ASP), and other experts, and eight focused on ASP only. Rigorous methods of thematic synthesis were drawn upon to construct analytical themes in line with the theoretical domains framework (TDF) and the capability, opportunity, and motivation model of behaviour (COM-B). A wide range of barriers and enablers were identified which influenced capability, opportunity, and motivation to participate in a clean sport environment. The weight of evidence pointed to limitations in the current anti-doping education system in providing athletes and ASP with the knowledge and skills to protect against doping, as well as the significant influence of social and cultural norms in shaping doping and clean sport behaviours through a shared social identity, and risky contexts leading to moments of vulnerability to doping. We identified a need for anti-doping programmes to move beyond the current focus on athlete capability, and address the opportunity and motivation components of clean sport behaviours through a targeted and tailored focus on education, training, persuasion, modelling and environmental restructuring interventions.

Fighting fair: community perspectives on the fairness of performance enhancement in esports

Aims

This study aims to explore community perspectives on enhancer usage in competitive gaming and esports, focusing on the perception of fairness and concerns about various potential performance enhancers.

Methods

We conducted both qualitative and quantitative surveys to understand the competitive gaming community's opinions on different types of performance enhancers and their potential impact on esports. A thematic analysis was performed to identify key themes in how players rationalize their opinions.

Conclusions

The gaming community differentiates between potential performance enhancers based on how problematic they are for the esports scene, with the most concern surrounding hard drugs, pharmaceuticals, and brain stimulation interventions. Participants who are more invested in competitive gaming tend to be more sceptical of enhancers and express greater concerns. Four themes were identified in the thematic analysis: (1) risk, (2) morality, (3) enhancer effects, and (4) regulation. To increase acceptance and perceived legitimacy in decision-making, it is recommended that regulators engage a variety of stakeholders in transparent decision-making processes when forming tournament rules and regulations. This will help address the fragmented regulatory landscape and prevent potential differences in the perception of tournament winners based on the governing body supervising the competition.

Effects of isometric training and R.I.C.E. treatment on the arm muscle performance of swimmers with elbow pain

The effects of IT and R.I.C.E. treatment on arm muscle performance in overhead athletes with elbow pain (EP) have been partially validated. However, there is a lack of research evidence regarding the efficacy of these two methods on arm muscle performance among swimmers with EP. The aim of this study was to investigate the trends and differences in the effects of IT and R.I.C.E. treatment on arm muscle performance among swimmers with EP. The main outcomes were the time effects and group effects of interventions on muscle voluntary contraction (MVC). Sixty elite freestyle swimmers from Tianjin, China, voluntarily participated in the study and completed a 10-week intervention program. Swimmers with EP in the IT group showed a positive trend in MVC, with an approximately 2% increase, whereas the MVC of subjects in the R.I.C.E. treatment group and control group decreased by approximately 4% and 5%, respectively. In comparison, the effects of the IT intervention on the MVC of the triceps and brachioradialis muscles in swimmers with EP were significant (p = 0.042 < 0.05, p = 0.027 < 0.05). The mean MVC value of the IT group (0.60) was greater than that of the other two groups (0.51, 0.50). IT has a beneficial impact on the MVC performance of the triceps and brachioradialis muscles in swimmers with EP. It is recommended that professionals consider incorporating IT into regular training routines to mitigate the risk of EP issues. Future research should examine the effectiveness of both interventions on hand-grip strength and completion time in 50-m freestyle swim drills in order for swimmers with EP to return to this sport.

A Review of Mental Health Issues in High-Performance and Elite-Level Cycling

Despite the public health benefits of cycling in the general population, mental health issues may be evident in high-performance and elite-level competitive domains. With prominent riders disclosing their experiences with psychiatric symptoms, distinctive socioenvironmental factors could exacerbate psychopathological vulnerabilities. This suggests a need for greater mental health awareness amongst stakeholders, supplemented by actions from international and national federations and regulators. To synthesise relevant observations about psychiatric concerns in high-performance and elite-level cycling, we conducted a keyword search of articles in APA PsycINFO, PubMed, and Scopus based on specified exclusion criteria. Thirteen papers were identified that examined mental health issues in high-performance and/or elite-level cycling per classifications from the World Health Organization's International Classification of Diseases 11th Revision. A large proportion of articles illustrated eating disorder symptomatology, but others discussed attention deficit/hyperactivity disorder, anxiety disorder, depression, sleep wake disorders, and substance use disorder. Existing literature underlines important considerations for all stakeholders within the cycling community around mental health initiatives and care provisions, which are currently lacking across the sport. Such programmes could incorporate consensus statements, psychiatric screening, psychoeducation, stigma-reducing policies, and athlete advocacy. These can help mitigate socioenvironmental risk factors and prioritise athlete wellbeing over performance-centred motivations.

Exercise-induced bronchoconstriction in elite athletes: a narrative review

Exercise-induced bronchoconstriction (EIB) is the most common chronic disease among elite athletes and when left untreated, can impact both respiratory health and sports performance. In recent years, there has been an increase in the awareness and detection of EIB in elite athletes. This narrative review aims to evaluate the risk, prevention, diagnosis, medication, and anti-doping policies of EIB in elite athletes, and to provide more references for athletes with EIB. The results showed that athletes of endurance, winter, and water sports generally have a higher prevalence of EIB than athletes of other sports. Adaptive warm-up before formal exercise and using heat exchange masks at low temperatures are effective ways for athletes to prevent EIB. For physicians, the exercise challenge test and eucapnic voluntary hyperpnea are the recommended diagnostic methods for EIB in athletes. The treatment of athletes with EIB is medication-based, such as inhaled corticosteroids and beta-2 agonists, but current anti-doping policies should be considered when used.

Salbutamol in the Management of Asthma: A Review

Asthma is a common inflammatory disease of the lungs. The prevalence of asthma is increasing worldwide, and the tendency indicates that the number of asthma sufferers will soar in the coming years for several reasons, in particular, the lifestyles we have adopted that expose us to risk factors. Salbutamol is the first selective short-acting β2-agonist (SABA) used as an alternative reliever in the treatment of asthma. Its therapeutic effect is based on its potent smooth muscle relaxant properties, which allow the inhibition of bronchial smooth muscle contraction and subsequent bronchodilation. Salbutamol can be administered orally, intravenously (IV), intramuscularly (IM), subcutaneously, or by inhalation. For this reason, the pharmacokinetic (PK) parameters-absorption, distribution, metabolism, and elimination-are highly diverse and, consequently, the efficacy and adverse effects also differ between each formulation. Here, we review the pharmacological profile of different salbutamol formulations, focusing on their efficacy and adverse effects for its original application, asthma.

The importance of institutional quality: Reviewing the relevance of Indonesia's Omnibus Law on national competitiveness

Institutional quality is significantly relevant in determining national competitiveness when reflected in economic growth and successful development. Quality institutions manifest in robust 'rules of the game' reflected by sound governance and policymaking in at least four streams: social, economic, administrative, and political. Policy reforms intended to improve national competitiveness should aim to strengthen the streams simultaneously, whereas partial reforms could instead lead to poorer outcomes. Through the lens of institutional quality analysis, this paper critically reviews the relevance of Indonesia's Job Creation Law, colloquially known as the Omnibus Law, to improve the country's national competitiveness as conceptually intended. Declared as an overarching regulatory framework, the Law postulates Indonesia as prospecting for increased foreign investments. However, the Law is a partial policy reform as it overlooks the pivotal aspects necessary to improve institutional quality in Indonesia, such as inter-community relations, intellectual property regime certainty, quality vocational education, and meritocratic political recruitment. Thus, regardless of the opportunities, the Law may bring about, it may weaken national competitiveness instead. The Law is currently ruled conditionally unconstitutional by Indonesia's Constitutional Court. If it is to be defended by the government, however, further multi-sectoral collaboration is necessary for the future implementation of the Law to enhance Indonesia's institutional quality. In a more global context, this review indicates how developing nations should be mindful of various non-economic aspects (e.g., cultural and educational levels of the population) when undertaking policy reforms especially to enhance their national competitiveness. There may be future downsides to these implications and as it is too early to critically assess them, there is an opportunity through time and future research to do so.

Research on Detection of Sterol Doping in Sports by Electrochemical Sensors: A Review

The use of doping by athletes to improve performance is prohibited. Therefore, doping testing is an important step to ensure fairness in sports. Doping is gradually metabolized in the body and is therefore difficult to detect immediately by a common method. At the same time, the emergence of new doping agents poses a challenge for highly sensitive detection. Electrochemical sensors are a fast, highly sensitive, and inexpensive analytical detection technology. It provides qualitative and quantitative determination of analytes by altering the electrochemical signal of the analyte or probe at the electrode. In this min-review, we summarized the different electrochemical sensing strategies for sterol doping detection. Some of the representative papers were interpreted in detail. In addition, we compare different sensing strategies.

International Olympic Committee (IOC) consensus statement on acute respiratory illness in athletes part 2: non-infective acute respiratory illness

Acute respiratory illness (ARill) is common and threatens the health of athletes. ARill in athletes forms a significant component of the work of Sport and Exercise Medicine (SEM) clinicians. The aim of this consensus is to provide the SEM clinician with an overview and practical clinical approach to non-infective ARill in athletes. The International Olympic Committee (IOC) Medical and Scientific Committee appointed an international consensus group to review ARill in athletes. Key areas of ARill in athletes were originally identified and six subgroups of the IOC Consensus group established to review the following aspects: (1) epidemiology/risk factors for ARill, (2) infective ARill, (3) non-infective ARill, (4) acute asthma/exercise-induced bronchoconstriction and related conditions, (5) effects of ARill on exercise/sports performance, medical complications/return-to-sport (RTS) and (6) acute nasal/laryngeal obstruction presenting as ARill. Following several reviews conducted by subgroups, the sections of the consensus documents were allocated to 'core' members for drafting and internal review. An advanced draft of the consensus document was discussed during a meeting of the main consensus core group, and final edits were completed prior to submission of the manuscript. This document (part 2) of this consensus focuses on respiratory conditions causing non-infective ARill in athletes. These include non-inflammatory obstructive nasal, laryngeal, tracheal or bronchial conditions or non-infective inflammatory conditions of the respiratory epithelium that affect the upper and/or lower airways, frequently as a continuum. The following aspects of more common as well as lesser-known non-infective ARill in athletes are reviewed: epidemiology, risk factors, pathology/pathophysiology, clinical presentation and diagnosis, management, prevention, medical considerations and risks of illness during exercise, effects of illness on exercise/sports performance and RTS guidelines.

Model‐based meta‐analysis of salbutamol pharmacokinetics and practical implications for doping control

Salbutamol was included in the prohibited list of the World Anti‐Doping Agency (WADA) in 2004. Although systemic intake is banned, inhalation for asthma is permitted but with dosage restrictions. The WADA established a urinary concentration threshold to distinguish accordingly prohibited systemic self‐administration from therapeutic prescription by inhalation. This study aimed at evaluating the ability of the WADA threshold to differentiate salbutamol therapeutic use from violation of antidoping rules. Concentration‐time profile of salbutamol in plasma and its excretion in urine was characterized through a model‐based meta‐analysis of individual and aggregate data collected after administration of a large range of doses following different modes of administration and under a variety of conditions. The developed model adequately fitted salbutamol plasma and urine concentration‐time profiles of the 13 selected studies. Model‐based simulations confirmed that a wide range of salbutamol urine concentrations might be measured after drug intake. Although violation of the WADA Code can be strongly suspected in individuals showing very high salbutamol urine concentrations, uncertainty remains for values close to the WADA threshold as they can be compatible with both permitted therapeutic use and violation. Although not entirely discriminant, the current WADA rule is globally supported by our appraisal. It could be further improved by a slight and reasonable adjustment of inhaled daily dosages allowed for therapeutic use. Our model might help antidoping experts in the evaluation of suspected doping cases through confronting the athlete's urine measurements with their allegations about salbutamol treatment.

Packaging and Delivery of Asthma Therapeutics

Asthma is a life-altering, chronic disease of heterogenous origin that features a complex interplay of immune and environmental signaling. Although very little progress has been made in prevention, diverse types of medications and delivery systems, including nanoscale systems, have been or are currently being developed to control airway inflammation and prevent exacerbations and fibrosis. These medications are delivered through mechanical methods, with various inhalers (with benefits and drawbacks) existing, and new types offering some variety in delivery. Of particular interest is the progress being made in nanosized materials for efficient penetration into the epithelial mucus layer and delivery into the deepest parts of the lungs. Liposomes, nanoparticles, and extracellular vesicles, both natural and synthetic, have been explored in animal models of asthma and have produced promising results. This review will summarize and synthesize the latest developments in both macro-(inhaler) and micro-sized delivery systems for the purpose of treating asthma patients.

Prevalence of lower airway dysfunction in athletes: a systematic review and meta-analysis by a subgroup of the IOC consensus group on 'acute respiratory illness in the athlete'

OBJECTIVE

To report the prevalence of lower airway dysfunction in athletes and highlight risk factors and susceptible groups.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, EBSCOhost and Web of Science (1 January 1990 to 31 July 2020).

ELIGIBILITY CRITERIA

Original full-text studies, including male or female athletes/physically active individuals/military personnel (aged 15-65 years) who had a prior asthma diagnosis and/or underwent screening for lower airway dysfunction via self-report (ie, patient recall or questionnaires) or objective testing (ie, direct or indirect bronchial provocation challenge).

RESULTS

In total, 1284 studies were identified. Of these, 64 studies (n=37 643 athletes) from over 21 countries (81.3% European and North America) were included. The prevalence of lower airway dysfunction was 21.8% (95% CI 18.8% to 25.0%) and has remained stable over the past 30 years. The highest prevalence was observed in elite endurance athletes at 25.1% (95% CI 20.0% to 30.5%) (Q=293, I²=91%), those participating in aquatic (39.9%) (95% CI 23.4% to 57.1%) and winter-based sports (29.5%) (95% CI 22.5% to 36.8%). In studies that employed objective testing, the highest prevalence was observed in studies using direct bronchial provocation (32.8%) (95% CI 19.3% to 47.2%). A high degree of heterogeneity was observed between studies (I²=98%).

CONCLUSION

Lower airway dysfunction affects approximately one in five athletes, with the highest prevalence observed in those participating in elite endurance, aquatic and winter-based sporting disciplines. Further longitudinal, multicentre studies addressing causality (ie, training status/dose-response relationship) and evaluating preventative strategies to mitigate against the development of lower airway dysfunction remain an important priority for future research.

Frequency and type of adverse analytical findings in athletics: Differences among disciplines

Athletics is a highly diverse sport that contains a set of disciplines grouped into jumps, throws, races of varying distances, and combined events. From a physiological standpoint, the physical capabilities linked to success are quite different among disciplines, with varying involvements of muscle strength, muscle power, and endurance. Thus, the use of banned substances in athletics might be dictated by physical dimensions of each discipline. Thus, the aim of this investigation was to analyse the number and distribution of adverse analytical findings per drug class in athletic disciplines. The data included in this investigation were gathered from the Anti-Doping Testing Figure Report made available by the World Anti-Doping Agency (from 2016 to 2018). Interestingly, there were no differences in the frequency of adverse findings (overall,~0.95%, range from 0.77 to 1.70%) among disciplines despite long distance runners having the highest number of samples analysed per year (~9812 samples/year). Sprinters and throwers presented abnormally high proportions of adverse analytical findings within the group of anabolic agents (p < 0.01); middle- and long-distance runners presented atypically high proportions of findings related to peptide hormones and growth factors (p < 0.01); racewalkers presented atypically high proportions of banned diuretics and masking agents (p = 0.05). These results suggest that the proportion of athletes that are using banned substances is similar among the different disciplines of athletics. However, there are substantial differences in the class of drugs more commonly used in each discipline. This information can be used to effectively enhance anti-doping testing protocols in athletics.

Asthma medication in athletes: a qualitative investigation of adherence, avoidance and misuse in competitive sport

OBJECTIVES

The purpose of this qualitative study was to utilize the Capability, Opportunity, Motivation - Behavior model (COM-B) to: (1) evaluate athlete knowledge and understanding of current asthma-related anti-doping regulations, (2) explore the impact of environmental and societal influences on athletes with asthma, and (3) examine athlete perception of asthma medication use in competitive sport.Methods: Semi-structured interviews were conducted with ten competitive endurance athletes (five athletes with asthma and five without asthma). Interviews were guided by the COM-B model and transcripts were analyzed inductively and deductively using reflexive thematic analysis.Results: Mapping the experiences and perceptions of athletes against an established behavioral framework identified that: (1) athletes' possess limited knowledge and understanding of the World Anti-Doping Agency (WADA) Prohibited List and Therapeutic use exemption (TUE) policy with respect to asthma medication; (2) the use of sub-optimal diagnostic methods is commonplace and increases the risk of misdiagnosis and unnecessary inhaler therapy; (3) negative media portrayal of high-profile asthma-related doping allegations impacts public opinion and contributes to the perception of wrongdoing within the sporting community.Conclusion: The novel application of behavioral science highlights several factors that may contribute to asthma medication avoidance and promote misuse in competitive sport. The findings from this study provide a foundation for the development and implementation of targeted education programmes, and it is hoped that employing this approach will ultimately improve overall perceptions of asthma treatment in athletes, which is necessary to maintain respiratory health, optimize performance and protect the integrity of sport.

© 2021 The Author(s). Published with license by Taylor & Francis Group, LLC.

Special Considerations and Perspectives for Exercise-Induced Bronchoconstriction (EIB) in Olympic and Other Elite Athletes

Diagnosing and treating elite and Olympic athletes with exercise-induced bronchoconstriction has been well established. However, a subset of elite and Olympic athletes with exercise-induced bronchoconstriction experience symptoms of breathlessness due to lack of adherence, improper medications, and/or generalized breathing dysfunction. A short review of traditional treatment plans for elite and Olympic athletes is presented along with the challenges of adherence, managing dysfunctional breathing, and measuring and treating mental skills deficits that may impact breathing. Elite and Olympic athletes may not respond to traditional treatment for exercise-induced bronchospasm, and we present some of the reasons why the athletes fail to respond. Furthermore, we present information on how to detect and treat elite and Olympic athletes with difficult-to-treat asthma. As part of this review we developed a flow diagram for medical providers to identify the reasons for lack of response to traditional treatment plans for exercise-induced bronchoconstriction with options for other treatment modalities.