Factor for middle ear effusion fluid build up in

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factor for middle ear effusion (fluid build-up in middle ear), which in turn is a risk factor for hearing damage, Morgan and Shenoi (1989) investigated the acute effects of swimming on Eustachian tube function of 30 children aged between four and eight years with healthy middle ears (Morgan and Shenoi, 1989). Standard tympanometry assessments prior to swimming, 30-45 minutes after swimming and 14 hours post swimming revealed that swimming did not affect Eustachian tube function of children. Similarly, Grace and colleagues found that middle ear pressure was not adversely affected in 52 healthy schoolchildren who completed an average of four swim bouts (Grace et al., 1987). Characteristics of studies can be found in Table 1. In the third eligible study, reported solely on free radical scavenging activity in a sample of children and adolescents (mean age: 11.8 years) (Atsumi et al., 2008). The authors (2008) found that free radical scavenging activity was significantly reduced after 50 minutes of swimming compared to resting levels, suggesting that, similar to other forms of exercise, swimming acutely reduces anti-oxidative capacity due to the production of free radicals/reactive oxygen species during exercise (Atsumi et al., 2008). Two of the studies were at a high risk of selection bias because they were non-randomised controlled trials (Atsumi et al., 2008, Grace et al., 1987), whereas, the other study was at an unclear risk of selection bias because the authors did not provide information regarding the randomisation method used (Morgan and Shenoi, 1989) (see Figure 3 and Appendix D). All three studies were at a low risk of attrition bias because all participants completed each of the assessments. None of the studies compared the responses to swimming versus other modes of exercise in a crossover design. We found no data on the cardiorespiratory responses to swimming. Therefore, future studies are required to investigate the comparative physiological responses to swimming compared to other modes of exercise in crossover design studies (with randomised order of condition) in a sufficient number of children. Healthy university students and adults Nine eligible studies (3 single group studies, 2 single group studies with crossover, and 4 CT with crossover) investigated the acute effects of swimming on healthy adults (Böning et al., 1988, Dixon and Faulkner, 1975, Galbo et al., 1979, Holmer, 1972, Holmer and Bergh 1974, Lakin et al., 2013, Ueda and Kurokawa, 1995, Viti et al., 1989, Weiss et al., 1988). The duration of the single bout of exercise also varied considerably from one hour (Galbo et al., 1979, Böning et al., 1988) to a 5-8 minutes swimming test (Holmer and Bergh 1974). The majority of these studies investigated the effects of breaststroke swimming (Böning et al., 1988, Galbo et al., 1979, Holmer, 1972, Ueda and
49 Chapter 3 The physiological effects of swimming: a systematic review Kurokawa, 1995, Weiss et al., 1988), whereas, two studies employed backstroke (Holmer, 1972, Viti et al., 1989), one study used front crawl (Dixon and Faulkner, 1975), and two studies did not report the swim stroke used (Holmer and

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