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OBJECTIVE: Physical inactivity is a significant contributor to many acute and chronic medical conditions. While the dangers of physical inactivity (PA) are well understood and physicians have the desire to address them, a lack of education in exercise prescription (ERx) may be a barrier to properly prescribing exercise to patients. The aim of this research was to determine the effectiveness of an ERx medical education lecture and provide evidence for the need for formal ERx education among students and physicians in training with a secondary goal of further exploring medical student and resident habits and beliefs about PA and ERx. METHODS: A one-hour education session was developed based on the American College of Sports Medicine principles of ERx. Pre- and postsurveys were administered immediately before and after the curriculum session to Wayne State University School of Medicine medical students and residents to assess perceived ERx knowledge level and confidence levels for prescribing aerobic and resistance exercise to patients. Virtual curriculum sessions were held over Zoom. RESULTS: A total of 144 presurvey and 119 postsurvey results were analyzed. The mean perceived ERx knowledge level significantly increased from 4.67/10 ± 1.98 to 7.35/10 ± 1.56 (P <.001). Mean confidence level discussing PA with patients, ability to answer exercise-related questions, confidence level in ability to prescribe aerobic exercise, and ability to prescribe resistance exercise significantly increased in all groups and overall (P <.001) CONCLUSION: A one-hour session to educate medical students and residents on how to write an ERx improved perceived knowledge and confidence in this subject matter. Although further study is needed to determine long-term knowledge retention and the impact on ERx behavioral practice in a patient care setting, this study provides preliminary evidence to justify its inclusion as a regular component of the medical school curriculum. [ABSTRACT FROM AUTHOR]

Context: Male amateur marathon runners represent a unique subset of the population who may be at increased risk of cardiovascular disease (CVD) due to their underlying risk factors and their involvement in vigorous exercise such as marathon running. Objective: To assess the modifiable risk factors (MRFs) of CVD in experienced male amateur marathon runners and health interventions on CVD risk factors. Data Sources: CINAHL, Cochrane Library, Embase, Medline, and SPORTDiscus. Study Selection: Studies selected according to the inclusion criteria. Study Design: Systematic review. Level of Evidence: Level 3. Data Extraction: The publication dates included were from June 1, 2008 to February 29, 2020. Published primary epidemiological, observational, randomized controlled trial (RCT) and/or non-RCT studies assessing the MRFs of CVD and health interventions on CVD risk factors in male amateur marathon runners aged ≥18 years and written in the English language were included in the review. Results: Five studies met the inclusion criteria for analysis. These included male amateur marathon runners (n = 862), aged 42 to 77 years. Hypertension, hyperlipidemia, smoking, and alcohol use were MRFs positively associated with an increased risk of coronary atherosclerosis found in a subset of male marathon runners. No studies examined health interventions on CVD risk factors in any of the included studies. All 5 studies were of good quality from the National Heart, Lung, and Blood Institute quality assessment tools used. The risk of bias was low to moderate. Conclusion: There is a paucity of observational studies evaluating the CVD MRFs. Negative lifestyle behaviors exist within this population despite their engagement in physical exercise through marathon running. Marathon running does not negate the long-term effects caused by past negative lifestyle behaviors. This systematic review identifies that this population may not be aware of their possible risk of atherosclerosis and, consequently, CVD. [ABSTRACT FROM AUTHOR]

Pseudoaneurysm of the lateral perforating branch of the peroneal artery is exceedingly rare. To our knowledge, eight cases are described in the current literature, with five occurring as a result of trauma and the remainder being iatrogenic. We present a pseudoaneurysm of the lateral perforating peroneal artery in a professional athlete following an inversion-plantarflexion injury of the ankle. He described persistent pain and fluctuant swelling to the lateral aspect of the right ankle with sudden onset of increased pain and swelling 10 days after the initial injury. Arterial duplex identified a pseudoaneurysm of the right lateral perforating peroneal artery. Endovascular coil embolisation of the aneurysm resulted in almost immediate improvement in symptoms. The patient has since regained full function of the affected ankle. This case report highlights the necessity for clinicians to maintain a high index of suspicion in order to promptly investigate and appropriately manage this pathology., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

BackgroundIn Fontans, exercise tolerance is poorer compared to their healthy peers. Higher V˙O2peak represents a strong predictor for mortality and morbidity in these patients. Cardiac rehabilitation programs have been shown to improve cardiopulmonary function in Fontans. More habitual physical activity should therefore lead to a better exercise tolerance.MethodsWe performed cardiopulmonary exercise testing in 24 Fontan patients who had engaged in physical activity for a minimum of 3 h per week over their lifetime. As a control we performed cardiopulmonary exercise testing in 20 Fontan patients who had undertaken no physical activity or

Abstract Background Surfing is a popular sport in Australia, accounting for nearly 10% of the population. External auditory exostosis (EAE), also referred to as surfer’s ear, is recognized as a potentially serious complication of surfing. Cold water (water temperature below 19 °C) is a commonly cited risk factor, with prevalence of EAE in cold water surfers ranging from 61 to 80%. However, there is a paucity of studies reporting the prevalence of EAE in surfers exposed to water temperatures above 19 °C. With mean water temperature ranging from 19 °C to 28 °C, the Gold Coast region of Australia provides the ideal environment to assess the main goal of this study: to assess the prevalence and severity of EAE in warm water surfers. Methods Eligible participants were surfers living and surfing on the Gold Coast (Queensland, Australia). Currently active surfers over 18 years of age, surfing year-round, with a minimum of five consecutive years of surfing experience were recruited to participate. Included individuals were asked to complete a questionnaire and underwent bilateral otoscopy. Results A total of 85 surfers were included, with mean age 52.1 years (standard deviation [SD] ±12.6 years) and mean surfing experience of 35.5 years (SD ±14.7 years). Nearly two-thirds of participants (65.9%) had regular otological symptoms, most commonly water trapping (66%), hearing loss (48.2%), and cerumen impaction (35.7%). Less than one-fifth of the surfers (17.7%) reported regular use of protective equipment for EAE. The overall prevalence of exostosis was 71.8%, with most of the individuals having bilateral lesions (59%) and a mild grade (grade 1, 47.5%). There was insufficient evidence for any significant associations between the main outcomes (presence and severity of EAE) and factors related to age, surfing experience, winter exposure, surfing ability, symptoms, and use of protective equipment. Conclusion To the best of our knowledge, this is the first study assessing EAE in surfers exposed to warm waters (above 19 °C). The prevalence of 71.8% highlights the high prevalence of the condition in the surfing population, regardless of water temperature. Future research should focus on ways to prevent EAE.

Professional team athletes experience a range of mental health problems, both sports and non-sports related. However, there is limited information available for those charged with responsibility for managing these mental health conditions, particularly within the context of professional sporting clubs. This paper reports on consensus findings from a study of club doctors, who are primary care providers for professional team athletes within a specific code, the Australian Football League (AFL). Drawing on findings from a systematic literature search, a two-round Delphi procedure was used to develop a consensus on best practice for managing mental health conditions for club doctors as primary care providers for professional team athletes. Participants in this study were current and former club doctors employed in professional AFL clubs across Australia, with 28 doctors participating across two survey rounds. Overall, 77 statements were presented, with 50 endorsed as essential or important by ≥ 80% of the participants across the two rounds. Primary themes across nine domains include: (1) Prevention and Mental Health Promotion Activities; (2) Screening; (3) Engaging External Specialists; (4) Duty of Care; (5) Treatment: Assessment, Treatment and Case Coordination; (6) Communication; (7) Confidentiality; (8) Sleep Management and (9) Substance Use Management. This study is the first to offer club doctors working in professional team settings consensus guidelines for the management of mental health conditions, and the opportunity for greater clarification and consistency in role delivery. [ABSTRACT FROM AUTHOR]

Exercise facilities play an important role in enhancing physical fitness and in supporting an active lifestyle among users. During the global coronavirus disease 2019 (COVID-19) pandemic, exercise facilities have been shut as part of the "physical distancing" policies in many countries. Exercise facilities have been considered "high-risk" places for transmission because of their enclosed environment, shared equipment and the close contact between users and staff. In Japan, in response to the COVID-19 clusters developed from the exercise facilities in the early phase of pandemic, the Fitness Industry Association of Japan released guidelines for gym managers, workers, and users in March. This commentary aims to introduce exercise facilities guidelines in Japan. This article provides reference for the rest of the world to reopen exercise facilities safely in the post pandemic period or to prevent future outbreaks of infectious disease. [ABSTRACT FROM AUTHOR]

ObjectiveThis study aimed to identify acute changes in biceps and supraspinatus tendon characteristics before and after a graded exercise test to exhaustion (GXT) in highly trained wheelchair rugby (WR) athletes. A secondary aspect was to define chronic tendon adaptations related to the impairment of the athlete and the occupation of the tendon within the subacromial space (occupation ratio).MethodsTwelve WR athletes with different impairments (age = 32 ± 6 years; body mass = 67.2 ± 11.2 kg; 9.0 ± 3.6 years competing) volunteered for this study. Performance Corrected Wheelchair Users Shoulder Pain Index was used to quantify shoulder pain. Quantitative Ultrasound Protocols (QUS) were used to define supraspinatus and biceps tendon thickness, echogenicity, and echogenicity ratio of both dominant and non-dominant shoulder before and after the GXT including 22 ± 3.1 min submaximal propulsion and 10.2 ± 1.7 min maximal propulsion on a treadmill. Furthermore, the acromio-humeral distance (AHD) defined from ultrasound (US) images was used to calculate the occupation ratios.ResultsA mixed-effect multilevel analysis that included shoulder as grouping variable, demonstrated a significant reduction in the echogenicity of the biceps following GXT whilst controlling for impairment [spinal cord injury (SCI) and non-SCI] and the occupation ratio (β = −9.01, SEβ = 2.72, p = 0.001, 95% CI = [−14.34; −3.68]). This points toward fluid inflow into the tendon that may be related to overload and acute inflammation. In addition, persons with a SCI (n = 8) had a thicker supraspinatus tendon in comparison to persons with non-SCI (n = 3) which may be related to chronic tendon adaptations (β = −0.53 mm, SEβ = 0.26, p = 0.038, 95% CI = [−1.04; −0.03]). Finally, a greater occupation ratio was associated with signs of tendinopathy (i.e., greater biceps and supraspinatus tendon thickness, and lower supraspinatus echogenicity and echogenicity ratio).ConclusionAcute biceps tendon adaptations in response to the GXT in highly trained WR athletes were evident with chronic adaptations in the supraspinatus tendon being related to the impairment of the athlete. Ultrasound can be used to monitor tendon adaptations in WR athletes for medical diagnosis to assist the scheduling and type of training.

In 2020, the IOC proposed a universal methodology for the recording and reporting of data for injury and illness in sport. Para sport is played by individuals with impairment, and they have a unique set of considerations not captured by these recommendations. Therefore, the aim of this addendum to IOC consensus statement was to guide the Para sport researcher through the complexities and nuances that should be taken into consideration when collecting, registering, reporting and interpreting data regarding Para athlete health. To develop this translation, experts in the field of Para sports medicine and epidemiology conducted a formal consensus development process, which began in March 2020 with the formation of a consensus group that worked over eight phases, incorporating three virtual consensus meetings to finalise the translation. This translation is consistent with the IOC consensus statement, yet provides more detailed Para athlete specific definitions and recommendations on study population, specifically, diagnostic and eligible impairment categorisation and recording of adaptive equipment, and defining and classifying health problems in the context of Para sport. Additionally, recommendations and Para athlete specific examples are described with regards to injury mechanism, mode of onset, injury and illness classification, duration, capturing and reporting exposure and risk. Finally, methods and considerations are provided to cater to the varied needs of athletes with impairment with respect to data collection tools. This harmonisation will allow the science to develop and facilitate a more accurate understanding of injury and illness patterns for tailoring evidence-informed prevention programmes and enabling better planning of medical services for Para sport events. [ABSTRACT FROM AUTHOR]

Popliteal artery entrapment syndrome (PAES) is a rare cause of intermittent claudication in the young. Aberrant embryological development results in entrapment of the popliteal artery by myofascial structures of the popliteal fossa. Type 4 PAES is due to aberrant development of the popliteus muscle superficial to the popliteal artery. We present a case of bilateral type 4 PAES, along with intraoperative photography highlighting the anatomical cause for this pathology. Both limbs in this patient were treated successfully with surgical release of the entrapping popliteus muscle via a posterior surgical approach to the popliteal fossa. This report emphasises the importance of determining popliteal artery integrity and entrapment subtype to guide the management of this condition., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Previous studies have shown low to moderate evidence for a variety of magnetic resonance imaging (MRI) features as prognostic factors in athletes with hamstring injuries. Short-tau inversion recovery (STIR) signal intensity has not yet been investigated for assessing the prognosis of acute muscle injuries. Our aim was to explore the relationship between MRI STIR signal intensity and time to return to play (RTP) and to investigate the association between MRI STIR and reinjury risk in athletes with acute hamstring injuries.Study Design: Case-control study.Methods: We used MRI STIR to measure intramuscular signal intensity in patients with clinically diagnosed hamstring injuries at two time points: at injury and RTP. At injury, we calculated the association of MRI STIR signal intensity with the time to RTP and reinjury risk. At RTP, the association of MRI STIR signal intensity and reinjury risk and the change in MRI STIR signal intensity over time on reinjury risk was evaluated.Results: 51 patients were included. We found increased MRI STIR signal intensity: (1) at time of injury not to be associated with time to RTP, (2) at time of injury to be associated with a slightly lower risk for reinjury: odds 0.986 (0.975-0.998, p=0.02) and (3) at RTP not to be associated with reinjury risk. (4) We found no association between the change in MRI STIR signal intensity over time and reinjury risk.Conclusion: Increased MRI STIR signal intensity at injury has no value in time to RTP prognosis, but is associated with a reduced reinjury risk. [ABSTRACT FROM AUTHOR]

Aim: To describe the periodic health evaluation (PHE) practices of the top performing National Olympic Committees (NOCs).Methods: We sent a survey to NOCs finishing in the top 8 for medal count at the 2016 Rio Olympic Games or 2018 PyeongChang Olympic Games. The survey included four sections: (1) PHE staff composition and roles, (2) beliefs regarding the PHE, (3) a ranking of risk factors for future injury and (4) details on the elements of the PHE.Results: All 14 NOCs with top 8 finishes at the 2016 Rio Olympic Games or 2018 PyeongChang Olympic Games completed the survey. NOCs included a median of seven staff specialties in the PHE, with physicians and physiotherapists having the highest level of involvement. There was agreement that PHEs are effective in identifying current health conditions (13/14) and that athletes should receive individualised action plans after their PHE (14/14), but less agreement (6/14) that PHEs can predict future injury. The practices of NOCs were diverse and often specific to the athlete population being tested, but always included the patient's health history, laboratory studies, cardiovascular screening and assessments of movement capacity. The top three risk factors for future injury were thought to be previous injury, age and training experience.Conclusions: Among the top performing NOCs, the PHE is a comprehensive, multidisciplinary process aimed to identify existing conditions and provide baseline health and performance profiles in the event of future injury. Research linking PHEs to injury prevention is needed. [ABSTRACT FROM AUTHOR]

Objectives: To describe the incidence rate, severity, burden and aetiology of medical attention and time-loss injuries across five consecutive seasons at a professional ballet company.Methods: Medical attention injuries, time-loss injuries and dance exposure hours of 123 professional ballet dancers (women: n=66, age: 28.0±8.3 years; men: n=57, age: 27.9±8.5 years) were prospectively recorded between the 2015/2016 and 2019/2020 seasons.Results: The incidence rate (per 1000 hours) of medical attention injury was 3.9 (95% CI 3.3 to 4.4) for women and 3.1 (95% CI 2.6 to 3.5) for men. The incidence rate (per 1000 hours) of time-loss injury was 1.2 (95% CI 1.0 to 1.5) for women and 1.1 (95% CI 0.9 to 1.3) for men. First Soloists and Principals experienced between 2.0-2.2 additional medical attention injuries per 1000 hours and 0.9-1.1 additional time-loss injuries per 1000 hours compared with Apprentices (p≤0.025). Further, intraseason differences were observed in medical attention, but not time-loss, injury incidence rates with the highest incidence rates in early (August and September) and late (June) season months. Thirty-five per cent of time-loss injuries resulted in over 28 days of modified dance training. A greater percentage of time-loss injuries were classified as overuse (women: 50%; men: 51%) compared with traumatic (women: 40%; men: 41%).Conclusion: This is the first study to report the incidence rate of medical attention and time-loss injuries in professional ballet dancers. Incidence rates differed across company ranks and months, which may inform targeted injury prevention strategies. [ABSTRACT FROM AUTHOR]

Assessing vital signs such as heart rate (HR) by wearable devices in a lifestyle-related environment provides widespread opportunities for public health related research and applications. Commonly, consumer wearable devices assessing HR are based on photoplethysmography (PPG), where HR is determined by absorption and reflection of emitted light by the blood. However, methodological differences and shortcomings in the validation process hamper the comparability of the validity of various wearable devices assessing HR. Towards Intelligent Health and Well-Being: Network of Physical Activity Assessment (INTERLIVE) is a joint European initiative of six universities and one industrial partner. The consortium was founded in 2019 and strives towards developing best-practice recommendations for evaluating the validity of consumer wearables and smartphones. This expert statement presents a best-practice validation protocol for consumer wearables assessing HR by PPG. The recommendations were developed through the following multi-stage process: (1) a systematic literature review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, (2) an unstructured review of the wider literature pertaining to factors that may introduce bias during the validation of these devices and (3) evidence-informed expert opinions of the INTERLIVE Network. A total of 44 articles were deemed eligible and retrieved through our systematic literature review. Based on these studies, a wider literature review and our evidence-informed expert opinions, we propose a validation framework with standardised recommendations using six domains: considerations for the target population, criterion measure, index measure, testing conditions, data processing and the statistical analysis. As such, this paper presents recommendations to standardise the validity testing and reporting of PPG-based HR wearables used by consumers. Moreover, checklists are provided to guide the validation protocol development and reporting. This will ensure that manufacturers, consumers, healthcare providers and researchers use wearables safely and to its full potential. [ABSTRACT FROM AUTHOR]

The systemic effect of glucocorticoids (GCs) following injectable routes of administration presents a potential risk to both improving performance and causing harm to health in athletes. This review evaluates the current GC antidoping regulations defined by the World Anti-Doping Agency and presents a novel approach for defining permitted and prohibited use of glucocorticoids in sport based on the pharmacological potential for performance enhancement (PE) and risk of adverse effects on health. Known performance-enhancing doses of glucocorticoids are expressed in terms of cortisol-equivalent doses and thereby the dose associated with a high potential for PE for any GC and route of administration can be derived. Consequently, revised and substance-specific laboratory reporting values are presented to better distinguish between prohibited and permitted use in sport. In addition, washout periods are presented to enable clinicians to prescribe glucocorticoids safely and to avoid the risk of athletes testing positive for a doping test. [ABSTRACT FROM AUTHOR]

Background: Surfing is a popular sport in Australia, accounting for nearly 10% of the population. External auditory exostosis (EAE), also referred to as surfer's ear, is recognized as a potentially serious complication of surfing. Cold water (water temperature below 19 °C) is a commonly cited risk factor, with prevalence of EAE in cold water surfers ranging from 61 to 80%. However, there is a paucity of studies reporting the prevalence of EAE in surfers exposed to water temperatures above 19 °C. With mean water temperature ranging from 19 °C to 28 °C, the Gold Coast region of Australia provides the ideal environment to assess the main goal of this study: to assess the prevalence and severity of EAE in warm water surfers. Methods: Eligible participants were surfers living and surfing on the Gold Coast (Queensland, Australia). Currently active surfers over 18 years of age, surfing year-round, with a minimum of five consecutive years of surfing experience were recruited to participate. Included individuals were asked to complete a questionnaire and underwent bilateral otoscopy. Results: A total of 85 surfers were included, with mean age 52.1 years (standard deviation [SD] ±12.6 years) and mean surfing experience of 35.5 years (SD ±14.7 years). Nearly two-thirds of participants (65.9%) had regular otological symptoms, most commonly water trapping (66%), hearing loss (48.2%), and cerumen impaction (35.7%). Less than one-fifth of the surfers (17.7%) reported regular use of protective equipment for EAE. The overall prevalence of exostosis was 71.8%, with most of the individuals having bilateral lesions (59%) and a mild grade (grade 1, 47.5%). There was insufficient evidence for any significant associations between the main outcomes (presence and severity of EAE) and factors related to age, surfing experience, winter exposure, surfing ability, symptoms, and use of protective equipment. Conclusion: To the best of our knowledge, this is the first study assessing EAE in surfers exposed to warm waters (above 19 °C). The prevalence of 71.8% highlights the high prevalence of the condition in the surfing population, regardless of water temperature. Future research should focus on ways to prevent EAE. [ABSTRACT FROM AUTHOR]

Objectives: The menstrual cycle can affect sports participation and exercise performance. There are very few data on specific menstrual cycle symptoms (symptoms during various phases of the cycle, not only during menstruation) experienced by exercising women. We aimed to characterise the most common symptoms, as well as the number and frequency of symptoms, and evaluate whether menstrual cycle symptoms are associated with sporting outcomes.Methods: 6812 adult women of reproductive age (mean age: 38.3 (8.7) years) who were not using combined hormonal contraception were recruited via the Strava exercise app user database and completed a 39-part survey. Respondents were from seven geographical areas, and the questions were translated and localised to each region (Brazil, n=892; France, n=1355; Germany, n=839; Spain, n=834; UK and Ireland, n=1350; and USA, n=1542). The survey captured exercise behaviours, current menstrual status, presence and frequency of menstrual cycle symptoms, medication use for symptoms, perceived effects of the menstrual cycle on exercise and work behaviours, and history of hormonal contraception use. We propose a novel Menstrual Symptom index (MSi) based on the presence and frequency of 18 commonly reported symptoms (range 0-54, where 54 would correspond to all 18 symptoms each occurring very frequently).Results: The most prevalent menstrual cycle symptoms were mood changes/anxiety (90.6%), tiredness/fatigue (86.2%), stomach cramps (84.2%) and breast pain/tenderness (83.1%). After controlling for body mass index, training volume and age, the MSi was associated with a greater likelihood of missing or changing training (OR=1.09 (CI 1.08 to 1.10); p≤0.05), missing a sporting event/competition (OR=1.07 (CI 1.06 to 1.08); p≤0.05), absenteeism from work/academia (OR=1.08 (CI 1.07 to 1.09); p≤0.05) and use of pain medication (OR=1.09 (CI 1.08 to 1.09); p≤0.05).Conclusion: Menstrual cycle symptoms are very common in exercising women, and women report that these symptoms compromise their exercise participation and work capacity. The MSi needs to be formally validated (psychometrics); at present, it provides an easy way to quantify the frequency of menstrual cycle symptoms. [ABSTRACT FROM AUTHOR]

Objective: To investigate the comparative effectiveness of all treatments for patellofemoral pain (PFP).Design: Living systematic review with network meta-analysis (NMA).Data Sources: Sensitive search in seven databases, three grey literature resources and four trial registers.Eligibility Criteria: Randomised controlled trials evaluating any treatment for PFP with outcomes 'any improvement', and pain intensity.Data Extraction: Two reviewers independently extracted data and assessed risk of bias with Risk of Bias Tool V.2. We used Grading of Recommendations, Assessment, Development and Evaluation to appraise the strength of the evidence.Primary Outcome Measure: 'Any improvement' measured with a Global Rating of Change Scale.Results: Twenty-two trials (with forty-eight treatment arms) were included, of which approximately 10 (45%) were at high risk of bias for the primary outcome. Most comparisons had a low to very low strength of the evidence. All treatments were better than wait and see for any improvement at 3 months (education (OR 9.6, 95% credible interval (CrI): 2.2 to 48.8); exercise (OR 13.0, 95% CrI: 2.4 to 83.5); education+orthosis (OR 16.5, 95% CrI: 4.9 to 65.8); education+exercise+patellar taping/mobilisations (OR 25.2, 95% CrI: 5.7 to 130.3) and education+exercise+patellar taping/mobilisations+orthosis (OR 38.8, 95% CrI: 7.3 to 236.9)). Education+exercise+patellar taping/mobilisations, with (OR 4.0, 95% CrI: 1.5 to 11.8) or without orthosis (OR 2.6, 95% CrI: 1.7 to 4.2), were superior to education alone. At 12 months, education or education+any combination yielded similar improvement rates.Summary/conclusion: Education combined with a physical treatment (exercise, orthoses or patellar taping/mobilisation) is most likely to be effective at 3 months. At 12 months, education appears comparable to education with a physical treatment. There was insufficient evidence to recommend a specific type of physical treatment over another. All treatments in our NMA were superior to wait and see at 3 months, and we recommend avoiding a wait-and-see approach.Prospero Registeration Number: PROSPERO registration CRD42018079502. [ABSTRACT FROM AUTHOR]

Research reports limited, mixed evidence on the effectiveness of physiotherapy management in the treatment of femoroacetabular impingement (FAI) syndrome. The purpose of this review was to (1) identify what therapeutic exercises are being utilized in the non-surgical management of patients with FAI syndrome; (2) map the extent to which reported exercises reflect contributory pathomechanics associated with FAI syndrome. Scoping Review. MEDLINE, PubMed, CINAHL, SPORTDiscus, and PEDRO electronic databases were searched for studies that implemented a non-surgical, exercise-based treatment approach in patients with FAI syndrome. Exercises were extracted and analyzed according to elements recognized as contributing to the pathomechanics associated with FAI syndrome. 24 studies fulfilled the inclusion criteria. 453 exercises were extracted. Uniplanar exercises accounted for 338/453 or 74.6% of all reported exercises whereas triplanar exercises accounted for 21/453 or 4.6% of all exercises. Non-weight bearing exercises accounted for 220/453 or 48.6% of all exercises. The majority of therapeutic exercises were classified as sagittal, uniplanar exercises, utilizing a concentric exercise approach. These findings highlight that exercises utilizing triplanar, eccentric hip control, in a single limb weightbearing position are considerably underrepresented. • This scoping study maps currently prescribed exercises to pathomechanics in patients with FAI syndrome. • This study highlights a majority of prescribed exercises are uniplanar and non-weightbearing in patients with FAI syndrome. • Exercise design should incorporate exercises reflecting the contributing pathomechanics associated with FAI syndrome. [ABSTRACT FROM AUTHOR]

Advances in the field of medical sciences and medical technology, and present-day challenges, such as an aging population, rising medical expenses, and lifestyle-related diseases, have collectively catalyzed a research ecosystem termed "smart wellness." This article describes the establishment of a smart wellness service platform designed to empower individuals to create a sense of balance in their lives. Step-by-step details include service model, design, and architectural considerations. As a proof of concept, implementation details of a Health Improvement and Management Systems (HIMS) Hub, a Smart Wellness Service Platform deployed in six cities in South Korea, are presented. An on-site survey conducted in Busan Metropolitan City reveals the percentage of satisfied users to be 91.3%. Furthermore, data gathered from 27,236 physical evaluations of users from a Busan city center over the period of April 2013 to May 2018 reveal that males and females in their 50s and 60s account for the highest number of participants, while males in their 70s have a higher rate of participation than females in the same age group. [ABSTRACT FROM AUTHOR]

Extensive tendon ossification is thought to be rare and is hypothesised to occur due to cell-mediated tissue remodelling. Literature outlining risk factors for the development of an ossified segment, and then a consequent fracture is limited to case reports and case series. A woman in her fifties with a background of several autoimmune disorders presented to a sports and exercise medicine clinic with posterior ankle pain following a bout of brisk walking a month prior. CT and MRI imaging demonstrated a fractured extensively ossified segment of the corresponding Achilles tendon. Conservative treatment was trialled for six months, however, was unsuccessful. Surgical excision of the calcified fragment and flexor hallucis longus tendon transfer were suggested as a potential solution. This case is compared with and builds on current literature surrounding pathophysiology and optimal treatment of extensively ossified segments of the Achilles tendon., Competing Interests: Competing interests: JM is the honorary secretary for the British Orthopaedic Foot and Ankle Society. He also holds a consultancy agreement with Orthosolutions and Meshworks., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The COVID-19 pandemic forces sport and exercise medicine (SEM) physicians to think differently about the clinical care of patients. Many rapidly implement eHealth and telemedicine solutions specific to SEM without guidance on how best to provide these services.Aim: The aim of this paper is to present some guiding principles on how to plan for and perform an SEM consultation remotely (teleSEM) based on a narrative review of the literature. A secondary aim is to develop a generic teleSEM injury template.Results: eHealth and telemedicine are essential solutions to effective remote patient care, also in SEM. This paper provides guidance for wise planning and delivery of teleSEM. It is crucial for SEM physicians, technology providers and organisations to codesign teleSEM services, ideally involving athletes, coaches and other clinicians involved in the clinical care of athletes, and to gradually implement these services with appropriate support and education.Conclusion: teleSEM provides solutions for remote athlete clinical care during and after the COVID-19 pandemic. We define two new terms-eSEM and teleSEM and discuss guiding principles on how to plan for and perform SEM consultations remotely (teleSEM). We provide an example of a generic teleSEM injury assessment guide. [ABSTRACT FROM AUTHOR]

The highly infectious and pathogenic novel coronavirus (CoV), severe acute respiratory syndrome (SARS)-CoV-2, has emerged causing a global pandemic. Although COVID-19 predominantly affects the respiratory system, evidence indicates a multisystem disease which is frequently severe and often results in death. Long-term sequelae of COVID-19 are unknown, but evidence from previous CoV outbreaks demonstrates impaired pulmonary and physical function, reduced quality of life and emotional distress. Many COVID-19 survivors who require critical care may develop psychological, physical and cognitive impairments. There is a clear need for guidance on the rehabilitation of COVID-19 survivors. This consensus statement was developed by an expert panel in the fields of rehabilitation, sport and exercise medicine (SEM), rheumatology, psychiatry, general practice, psychology and specialist pain, working at the Defence Medical Rehabilitation Centre, Stanford Hall, UK. Seven teams appraised evidence for the following domains relating to COVID-19 rehabilitation requirements: pulmonary, cardiac, SEM, psychological, musculoskeletal, neurorehabilitation and general medical. A chair combined recommendations generated within teams. A writing committee prepared the consensus statement in accordance with the appraisal of guidelines research and evaluation criteria, grading all recommendations with levels of evidence. Authors scored their level of agreement with each recommendation on a scale of 0-10. Substantial agreement (range 7.5-10) was reached for 36 recommendations following a chaired agreement meeting that was attended by all authors. This consensus statement provides an overarching framework assimilating evidence and likely requirements of multidisciplinary rehabilitation post COVID-19 illness, for a target population of active individuals, including military personnel and athletes. [ABSTRACT FROM AUTHOR]

Background: The Sport Concussion Assessment Tool (SCAT) and Child SCAT are the 'gold standard' assessment tools for a suspected sport-related concussion (SRC). A number of 'modifiers' (eg, previous history of concussion) of a SRC have been identified. These may influence how the SCAT/Child SCAT results should be interpreted.Objectives: To achieve consensus, via an international panel of SRC experts, on which athlete/player and parent/caregiver demographic variables should be considered for inclusion in future editions of the SCAT/Child SCAT respectively.Methods: A two-round modified Delphi technique, overseen by a steering committee, invited 41 panellists to achieve expert consensus (≥80% agreement). The first round utilised open questions to generate demographic variables; the second round used a five-point ordinal item to rank the importance of including each variable in future editions of the SCAT/Child SCAT.Results: 15 experts participated in at least one Delphi round. 29 athlete/player and eight parent/caregiver variables reached consensus for inclusion in the SCAT, whereas two parent/caregiver variables reached consensus for exclusion. 28 athlete/player and four parent/caregiver variables reached consensus for the Child SCAT, whereas two parent/caregiver variables reached consensus for exclusion. Key categories of variables included the following: concussion/sport details, personal medical conditions and family medical history.Conclusion: This study provides a list of athlete/player and parent/caregiver demographic variables that should be considered in future revisions of the SCAT/Child SCAT. By considering (and ultimately likely including) a wider and standard set of additional demographic variables, the Concussion in Sport experts will be able to provide clinicians and researchers with data that may enhance interpretation of the individual's data and the building of larger datasets. [ABSTRACT FROM AUTHOR]

Aim To investigate if national, elite and age-grade rugby teams in Pacific rugby playing nations (Oceania Rugby) are supported by Physiotherapists and/or other sports and exercise medicine (SEM) professionals. Study Design Cross-sectional systematic website search with content analysis aligned with the Otago University's Pacific research protocols. Methods Fourteen Pacific rugby unions, as identified by Oceania Rugby's governing body, were included. The study employed a web-based search of the grey literature. Sources of information included blogs, news articles, Oceania Rugby and World Rugby websites, Facebook pages and websites of Pacific rugby playing unions. Data was extracted using a systematic methodology exploring the websites and Facebook pages available for each union. Data was collected between 24 July 2019 and 11 August 2019, and periodically monitored up until 1 September 2019. Results Of the 14 Unions included in the study, only five had independent websites. Thirteen Unions had an active and current Facebook page. Only three websites had information regarding Physiotherapists or SEM professionals for teams; although this information was also found for nine countries across 27 teams via news articles and, predominantly, Facebook. No qualifications were reported for any Physiotherapists or SEM professionals attached to these teams. Conclusions There is a need for Physiotherapists and SEM professionals to advocate for inclusion of their profiles in the public arena, to illustrate the integral role they play in support of player welfare within Pacific rugby teams. The presence of active and current websites for Pacific rugby unions should be encouraged, allowing for easier information sharing and promotion of these professions. [ABSTRACT FROM AUTHOR]

Research Question: Does the Nordic hamstring exercise (NHE) prevent hamstring injuries when included as part of an injury prevention intervention?Design: Systematic review and meta-analysis.Eligibility Criteria For Selecting Studies: We considered the population to be any athletes participating in any sporting activity, the intervention to be the NHE, the comparison to be usual training or other prevention programmes, which did not include the NHE, and the outcome to be the incidence or rate of hamstring injuries.Analysis: The effect of including the NHE in injury prevention programmes compared with controls on hamstring injuries was assessed in 15 studies that reported the incidence across different sports and age groups in both women and men.Data Sources: MEDLINE via PubMed, CINAHL via Ebsco, and OpenGrey.Results: There is a reduction in the overall injury risk ratio of 0.49 (95% CI 0.32 to 0.74, p=0.0008) in favour of programmes including the NHE. Secondary analyses when pooling the eight randomised control studies demonstrated a small increase in the overall injury risk ratio 0.52 (95% CI 0.32 to 0.85, p=0.0008), still in favour of the NHE. Additionally, when studies with a high risk of bias were removed (n=8), there is an increase of 0.06 in the risk ratio to 0.55 (95% CI 0.34 to 0.89, p=0.006).Conclusions: Programmes that include the NHE reduce hamstring injuries by up to 51%. The NHE essentially halves the rate of hamstring injuries across multiple sports in different athletes.Trial Registration Number: PROSPERO CRD42018106150. [ABSTRACT FROM AUTHOR]

This systematic review and meta-analysis aimed to examine the effects of physical exercise cum cognitive-behavioural therapy (CBT) on alleviating pain intensity, functional disabilities, and mood/mental symptoms in those suffering with chronic musculoskeletal pain. MEDLINE, EMBASE, PubMEd, PsycINFO and CINAHL were searched to identify relevant randomised controlled trials from inception to 31 December 2018. The inclusion criteria were: (a) adults ≥18 years old with chronic musculoskeletal pain ≥3 months, (b) randomised controlled design, (c) a treatment arm consisting of physical intervention and CBT combined, (d) the comparison arm being waitlist, usual care or other non-pharmacological interventions such as physical exercise or CBT alone, and (e) outcomes including pain intensity, pain-related functional disabilities (primary outcomes), or mood/mental symptoms (secondary outcome). The exclusion criteria were: (a) the presence of comorbid mental illnesses other than depression and anxiety and (b) non-English publication. The search resulted in 1696 records and 18 articles were selected for review. Results varied greatly across studies, with most studies reporting null or small effects but a few studies reporting very large effects up to 2-year follow-up. Pooled effect sizes (Hedges' g) were ~1.00 for pain intensity and functional disability, but no effect was found for mood/mental symptoms. The effects were mainly driven by several studies reporting unusually large differences between the exercise cum CBT intervention and exercise alone. When these outliers were removed, the effect on pain intensity disappeared at post-intervention while a weak effect (g = 0.21) favouring the combined intervention remained at follow-up assessment. More consistent effects were observed for functional disability, though the effects were small (g = 0.26 and 0.37 at post-intervention and follow-up respectively). More importantly, the value of adding CBT to exercise interventions is questionable, as consistent benefits were not seen. The clinical implications and directions for future research are discussed. [ABSTRACT FROM AUTHOR]

The Self-Determination Theory has been applied to explain behaviour in numerous contexts and cultures. In the exercise context, causality orientations (autonomy, control, impersonal) are important to describe individual differences in initiation and maintenance of health behaviour. The assessment of exercise causality orientations can be a key element to improve predictions of motivated health and exercise behaviour. Nevertheless, a scale to measure exercise causality orientations has not been established in German yet. Thus, it was the aim of the present work to translate the Exercise Causality Orientations Scale to German and to test it throughout three studies. The German G-ECOS questionnaire was cross-validated via confirmatory factor analyses in two separate samples. Both Study 1 (n = 306, 72.60% female, age M = 26.00, SD = 5.66; CFI = .96) and Study 2 (n = 320, 70.94% female, age M = 29.00, SD = 3.54; CFI = .95) indicated good model fits. In a further Study 3 (n = 548, 62.50% female, age M = 30.17, SD = 11.91), the relations between exercise causality orientations and other SDT related constructs were examined. The correlations indicated positive associations between autonomy causality orientation and intrinsic regulation, intrinsic exercise participation goals, and exercise basic needs satisfaction. Overall, the assessment of exercise causality orientations can be useful in analysing and potentially predicting motivated exercise behaviour. [ABSTRACT FROM AUTHOR]

Background: Understanding the cardiorespiratory factors related to the increase in oxygen consumption () during exercise is essential for improving cardiorespiratory fitness in individuals with stroke. However, cardiorespiratory factors related to the increase in during exercise in these individuals have not been examined using multivariate analysis. This study aimed to identify cardiorespiratory factors related to the increase in during a graded exercise in terms of respiratory function, cardiac function, and the ability of skeletal muscles to extract oxygen. Methods: Eighteen individuals with stroke (aged 60.1 ± 9.4 years, 67.1 ± 30.8 days poststroke) underwent a graded exercise test for the assessment of cardiorespiratory response to exercise. The increases in from rest to first threshold and that from rest to peak exercise were measured as a dependent variable. The increases in respiratory rate, tidal volume, minute ventilation, heart rate, stroke volume, cardiac output, and arterial-venous oxygen difference from rest to first threshold and those from rest to peak exercise were measured as the independent variables. Results: From rest to first threshold, the increases in arterial-venous oxygen difference (β = 0.711) and cardiac output (β = 0.572) were significant independent variables for the increase in (adjusted R2 = 0.877 p < 0.001). Similarly, from rest to peak exercise, the increases in arterial-venous oxygen difference (β = 0.665) and cardiac output (β = 0.636) were significant factors related to the increase in (adjusted R2 = 0.923, p < 0.001). Conclusion: Our results suggest that the ability of skeletal muscle to extract oxygen is a major cardiorespiratory factor related to the increase in during exercise testing in individuals with stroke. For improved cardiorespiratory fitness in individuals with stroke, the amount of functional muscle mass during exercise may need to be increased. [ABSTRACT FROM AUTHOR]

Pimobendan has gained enormous importance in the treatment of mitral valve disease in dogs. The current consensus statement of the American College of Veterinary Internal Medicine (ACVIM) recommends a treatment for dogs with symptomatic disease and dogs with asymptomatic disease with radiographic and echocardiographic signs of cardiomegaly. To investigate whether these dogs also benefit from a therapy with pimobendan, 21 dogs with mitral valve disease ACVIM B1 underwent a standardized submaximal exercise test on a treadmill. In this double-blinded and randomized study, the animals were divided into two groups, one receiving pimobendan and the other a placebo. At the first visit and at every follow-up appointment (at days 90 and 180), heart rate during the complete exercise test and lactate before and after running were measured. In addition to this, a questionnaire was completed by the dogs’ owners and all dogs were given an echocardiographic examination to detect any changes and to observe if the disease had progressed. Due to the diagnosis of leishmaniosis, one dog in the pimobendan group was retrospectively removed from the study so that 20 dogs were included for statistical analysis. No differences were observed at any time between the pimobendan-group and the placebo-group regarding heart rate. At day 180, the increase in lactate after exercise was significantly lower than in the placebo-group. The increase in the pimobendan-group at day 180 was lower than at day 90. Most of the dog owners from the pimobendan-group declared that their dogs were more active at day 90 (6/10) and at day 180 (8/10), while most dog owners from the placebo-group observed no changes regarding activity at day 90 (8/10) and day 180 (6/10). It can be concluded that the results of this study indicate that some dogs with mitral valve disease ACVIM B1 might benefit from a therapy with pimobendan. [ABSTRACT FROM AUTHOR]

Previous studies reported a significant association between postural control and lower-limb strength of several muscle groups, however, they were focused especially on knee muscles and ankle plantar and dorsal flexors. The aim of the present study is to examine the correlation between the muscle strength of ankle invertors, evertors, plantar flexors, and dorsal flexors and the control of bipedal stance in young and older adults. Thirty one young (aged 22.8 ± 2.6 years) and thirty one older adults (aged 70.5 ± 7.2 years) voluntarily participated in this study. Ankle muscle strength was evaluated by an isokinetic dynamometer. Normalized peak torque and work were averaged for four repetitions and for both lower limbs. The control of bipedal stance was evaluated by the sample entropy derived from an accelerometer placed on the lumbar spine while the subject stood on a foam pad with eyes open. Results showed significant age-related differences in ankle muscle strength and sample entropy in medial-lateral direction. More interestingly, the correlation between ankle muscle strength and the sample entropy was significantly different between young and older adults. Indeed, no significant correlation was observed in the younger adults. Conversely, in the older adults, the work of the ankle evertors positively correlated with sample entropy in the medial-lateral direction during bipedal stance (r = 0.36), whereas the peak torque and work of the dorsal flexors were significantly correlated with sample entropy in the anterior-posterior direction during bipedal stance (r = 0.44 for both variables). In the young adults, results suggest that, standing on foam with eyes open is a relatively easy postural task that does not require the full ankle muscle strength capacity. Taken together, the present findings suggest that older adults have a different association between ankle muscle strength and the sample entropy during bipedal stance. [ABSTRACT FROM AUTHOR]

Background: Physical therapy can prevent functional impairments and improve the quality of life of patients after hospital discharge. However, the effect of early mobilization on patients with a critical illness remains unclear. This study was performed to assess the evidence available regarding the effect of early mobilization on critically ill patients in the intensive care unit (ICU). Methods: Electronic databases were searched from their inception to March 21, 2019. Randomized controlled trials (RCTs) comprising critically ill patients who received early mobilization were included. The methodological quality and risk of bias of each eligible trial were assessed using the Cochrane Collaboration tool. Data were extracted using a standard collection form each included study, and processed using the Mantel-Haenszel (M-H) or inverse-variance (I-V) test in the STATA v12.0 statistical software. Results: A total of 1,898 records were screened. Twenty-three RCTs comprising 2,308 critically ill patients were ultimately included. Early mobilization decreased the incidence of ICU-acquired weakness (ICU-AW) at hospital discharge (three studies, 190 patients, relative risk (RR): 0.60, 95% confidence interval (CI) [0.40, 0.90]; p = 0.013, I2 = 0.0%), increased the number of patients who were able to stand (one study, 50 patients, 90% vs. 62%, p = 0.02), increased the number of ventilator-free days (six studies, 745 patients, standardized mean difference (SMD): 0.17, 95% CI [0.02, 0.31]; p = 0.023, I2 = 35.5%) during hospitalization, increased the distance the patient was able to walk unassisted (one study, 104 patients, 33.4 (0–91.4) meters vs. 0 (0–30.4) meters, p = 0.004) at hospital discharge, and increased the discharged-to-home rate (seven studies, 793 patients, RR: 1.16, 95% CI [1.00, 1.34]; p = 0.046). The mortality (28-day, ICU and hospital) and adverse event rates were moderately increased by early mobilization, but the differences were statistically non-significant. However, due to the substantial heterogeneity among the included studies, and the low quality of the evidence, the results of this study should be interpreted with caution. Publication bias was not identified. Conclusions: Early mobilization appears to decrease the incidence of ICU-AW, improve the functional capacity, and increase the number of ventilator-free days and the discharged-to-home rate for patients with a critical illness in the ICU setting. [ABSTRACT FROM AUTHOR]

Objective: To assess the use of diet and the use of exercise for prostate cancer (and/or its treatments’ side effects) by long-term survivors and whether such use is associated with selected socio-demographic, clinical, health-related quality-of-life (HRQOL) and psychological factors. Design, setting and participants: Population-based cohort study in New South Wales, Australia of prostate cancer survivors aged <70 years at diagnosis and who returned a 10-year follow-up questionnaire. Methods: Validated instruments assessed patient’s HRQOL and psychological well-being. Poisson regression was used to estimate adjusted relative proportions (RRs) of prostate cancer survivor groups who were currently eating differently (‘using diet’) or exercise differently (‘using exercise’) to help with their prostate cancer. Results: 996 (61.0% of 1634) participants completed the 10-year questionnaire of whom 118 (11.8%; 95%CI[9.8–13.9]) were using diet and 78 (7.8%; 95%CI[6.2–9.5]) were using exercise to help with their prostate cancer. Men were more likely to use diet or use exercise for prostate cancer if they were younger (p-trend = 0.020 for diet, p-trend = 0.045 for exercise), more educated (p-trend<0.001, p-trend = 0.011), support group participants (p-nominal<0.001, p-nominal = 0.005), had higher Gleason score at diagnosis (p-trend<0.001, p-trend = 0.002) and had knowledge of cancer spread (p-nominal = 0.002, p-nominal = 0.001). Use of diet was also associated with receipt of androgen deprivation therapy (RR = 1.59; 95%CI[1.04–2.45]), a greater fear of cancer recurrence (p-trend = 0.010), cognitive avoidance (p-trend = 0.025) and greater perceived control of cancer course (p-trend = 0.014). Use of exercise was also associated with receipt of prostatectomy (RR = 2.02; 95%CI[1.12–3.63]), receipt of androgen deprivation therapy (RR = 2.20; 95%CI[1.34–3.61]) and less satisfaction with medical treatments (p-trend = 0.044). Conclusions: Few long-term prostate cancer survivors use diet or exercise to help with their prostate cancer. Survivors may benefit from counselling on the scientific evidence supporting healthy eating and regular exercise for improving quality-of-life and cancer-related outcomes. [ABSTRACT FROM AUTHOR]

Athletes have the right to combine their sport and higher education careers (e.g., dual career), but differences in the recognition of the student-athlete’s status and availability of dual career programmes and services exist worldwide. The purpose of this study was to investigate the dual career phenomenon through the international student-athletes’ views. Student-athletes competing at the 2017 Summer Universiade were recruited to respond a 31-item online survey encompassing demographic characteristics (Q1-8), sport and university engagement (Q9-13), student-athletes’ knowledge and possible sources of information regarding dual career (Q14-22); and dual career support at personal, sport, and academic levels (Q23-31). Four hundred twenty-six respondents (males: 46%, females 54%), competing in 22 different sports (individual: 74%, team: 26%) from Africa (4%), America (20%), Asia (34%), Europe (39%), and Oceania (3), had experienced previous international sports events (94%). Differences among continents emerged for sport (p<0.001) and university (p = 0.039) engagement, and transfer time from home to the training venue (p = 0.030). Individual sports student-athletes showed higher sport engagement (p = 0.003) compared to team sports counterparts. Differences among university majors emerged for university engagement (p<0.001). Long absence from classes (57%), limited leisure time (50%), financial uncertainty (44%), reduction of training due to education (42%), and overload feelings (37%) emerged. The majority of the sample resulted not familiar with dual career programmes (60%) and public authorities (69%), envisaging national dual career policies at university (37%) and sport (25%) levels. Multiple relevant dual career supporters at personal, sport, and university levels were identified, mainly parents (86%) and coaches (65%). To strengthen the potential of the student-athletes of the future, a dual career network should be established among several stakeholders, for transnational cooperation and sharing of knowledge and best practices through extensive communication between policy-makers, practitioners and those having a strong supportive dual career role (e.g., parents, coaches, and university sport staff). [ABSTRACT FROM AUTHOR]

Elephant camps are among the most popular destinations in Thailand for tourists from many countries. A wide range of management strategies are used by these camps, which can have varied impacts on health and welfare of elephants. The objectives of this study were to examine relationships between FGM (fecal glucocorticoid metabolite) concentrations and camp management factors (work routine, walking, restraint, rest area, foraging), and to other welfare indicators (stereotypic behaviors, body condition, foot health, and skin wounds). Data were obtained on 84 elephants (18 males and 66 females) from 15 elephant camps over a 1-year period. Elephants were examined every 3 months and assigned a body condition score, foot score, and wound score. Fecal samples were collected twice monthly for FGM analysis. Contrary to some beliefs, elephants in the observation only program where mahouts did not carry an ankus for protection had higher FGM concentrations compared to those at camps that offered riding with a saddle and shows. Elephants that were tethered in the forest at night had lower FGM concentrations compared to elephants that were kept in open areas inside the camps. There was an inverse relationship between FGM concentrations and occurrence of stereotypy, which was not anticipated. Thus, assessing adrenal activity via monitoring of FGM concentrations can provide important information on factors affecting the well-being of elephants. Results suggest that more naturalistic housing conditions and providing opportunities to exercise may be good for elephants under human care in Thailand, and that a no riding, no hook policy does not necessarily guarantee good welfare. [ABSTRACT FROM AUTHOR]

Background: Physical exercise has been shown to be effective in relation to fatigue, aerobic fitness, and lower body strength in men with prostate cancer. However, research into the clinically relevant effects of interventions conducted in heterogeneous patient populations and in real-life clinical practice settings is warranted.Methods and Findings: We conducted a pragmatic, multicentre, parallel randomised controlled trial in 5 Danish urological departments. Recruitment began in May 2015, the first participant was randomised in June 2015, and the last participant was included in February 2017. In total, 214 men with prostate cancer were randomly assigned to either 6 months of free-of-charge football training twice weekly at a local club (football group [FG]) (n = 109) or usual care (usual care group [UG]) (n = 105), including brief information on physical activity recommendations at randomisation. Participants were on average 68.4 (SD 6.2) years old, 157 (73%) were retired, 87 (41%) were on castration-based treatment, 19 (9%) had received chemotherapy, and 41 (19%) had skeletal metastases at baseline. In this 1-year follow-up study, we evaluated the effects of community-based football training on the following outcomes: primary outcome, quality of life; secondary outcomes: continuation of football after 6 months, hip and lumbar spine bone mineral density (BMD), mental health score, fat and lean body mass, and safety outcomes, i.e., fractures, falls, and hospital admissions. Intention to treat (ITT) and per protocol (PP) analyses were conducted. No statistically significant between-group difference was observed in change in prostate-cancer-specific quality of life (ITT: 1.9 points [95% CI -1.9 to 5.8], p = 0.325; PP: 3.6 points [95% CI -0.9 to 8.2], p = 0.119). A statistically significant between-group difference was observed in change in total hip BMD, in favour of FG (0.007 g/cm2 [95% CI 0.004 to 0.013], p = 0.037). No differences were observed in change in lumbar spine BMD or lean body mass. Among patients allocated to football, 59% chose to continue playing football after the end of the 6-month intervention period. At 1-year follow-up in the PP population, FG participants had more improvement on the Mental Component Summary (2.9 [95% CI 0.0 to 5.7], p = 0.048 points higher) than UG participants, as well as a greater loss of fat mass (-0.9 kg [95% CI -1.7 to -0.1], p = 0.029). There were no differences between groups in relation to fractures or falls. Hospital admissions were more frequent in UG compared to FG (33 versus 20; the odds ratio based on PP analysis was 0.34 for FG compared to UG). There were 3 deaths in FG and 4 in UG. Main limitations of the study were the physically active control group and assessment of physical activity by means of self-report.Conclusions: In this trial, participants allocated to football appeared to have improved hip BMD and fewer hospital admissions. Men who played football more than once a week for 1 year lost fat mass and reported improved mental health. Community-based football proved to be acceptable, even when club membership was not subsidised.Trial Registration: ClinicalTrials.gov NCT02430792. [ABSTRACT FROM AUTHOR]

Hyperflexion injury to the metatarsophalangeal joint of the great toe, referred to as sand toe , can cause significant functional impairment. To our knowledge, there have been no radiological descriptions of this injury in the paediatric age group. Here, we report radiographic, sonographic and MRI findings in a male paediatric patient who sustained a sand toe injury, highlighting structural damage to the dorsomedial capsule and medial sagittal band, and discuss sand toe's favourable prognosis with conservative management., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Acute avulsion fracture of the base of the first metatarsal is a rare occurrence, caused by an eccentric contraction of the peroneus longus tendon insertion. A number of case reports have been published outlining various treatment strategies for treating this rare injury. Management plans range from conservative to operative options and include both acute and delayed operative treatments.We present our operative management strategy of an acute avulsion fracture of the base of the first metatarsal. It includes a step-by-step approach including intraoperative clinical photographs and intraoperative image intensifier images. We explain the rationale behind our operative approach and provide insight on the importance of recognising and treating this injury. Initially, this avulsion fracture might seem innocuous but if left untreated may result in disabling functional foot problems., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

McArdle disease is a glycogen storage disease that results in rhabdomyolysis during intense exercise. A number of different triggers have been described. We evaluated a patient with McArdle disease who presented with rhabdomyolysis after recreational scuba diving. There was no concern for barotrauma or decompression sickness. His symptoms resolved with standard-of-care management for non-diving-related rhabdomyolysis. Features of his experience provoked questions about the diving-related factors contributing to his presentation. We present the case and explore possible mechanisms of diving-related injury in patients with McArdle disease, including the possible effects of hyperoxia, hyperbaria, hypothermia and strenuous activity., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)