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Nutrition is vital for athletic performance, especially in ultra-endurance sports, which pose unique nutritional challenges. Despite its importance, there exist gaps in the nutrition knowledge among athletes, and emerging digital tools could potentially bridge this gap. The ULTRA-Q, a sports nutrition questionnaire adapted for ultra-endurance athletes, was used to assess the nutritional knowledge of ChatGPT-3.5, ChatGPT-4, Google Bard, and Microsoft Copilot. Their performance was compared with experienced ultra-endurance athletes, registered sports nutritionists and dietitians, and the general population. ChatGPT-4 demonstrated the highest accuracy (93%), followed by Microsoft Copilot (92%), Bard (84%), and ChatGPT-3.5 (83%). The averaged AI model achieved an overall score of 88%, with the highest score in Body Composition (94%) and the lowest in Nutrients (84%). The averaged AI model outperformed the general population by 31% points and ultra-endurance athletes by 20% points in overall knowledge. The AI model exhibited superior knowledge in Fluids, outperforming registered dietitians by 49% points, the general population by 42% points, and ultra-endurance athletes by 32% points. In Body Composition, the AI model surpassed the general population by 31% points and ultraendurance athletes by 24% points. In Supplements, it outperformed registered dietitians by 58% points and the general population by 55% points. Finally, in Nutrients and in Recovery, it outperformed the general population only, by 24% and 29% points, respectively. AI models show high proficiency in sports nutrition knowledge, potentially serving as valuable tools for nutritional education and advice. AI-generated insights could be integrated with expert human judgment for effective athlete performance optimization., (Copyright © Institute of Sport – National Research Instutite.)

External motivational stimuli have been shown to improve athletic performance. However, the neurophysiological mechanisms underlying this improvement remain poorly understood. This randomized crossover study investigated the effects of music and verbal encouragement on measures of muscle excitation and myoelectric manifestations of fatigue in the biceps brachii and brachioradialis muscles during an endurance task. Fifteen untrained (mean age 29.57 ± 2.77 years) and 13 trained individuals (mean age 32.92 ± 2.90 years) were included. The endurance task, performed to exhaustion, consisted of keeping the dominant arm flexed to 90 degrees while holding a dumbbell loaded to 80% of 1RM with a supine grip in three randomized conditions: standard, with self-selected music, and with verbal encouragement. The untrained subjects showed an increase in task duration of 15.26% ( p < 0.003) with music and 15.85% ( p < 0.002) with verbal encouragement compared to the condition without external stimuli. There were no significant differences in the myoelectric manifestations of fatigue between the different conditions. Regarding the muscle excitation metrics, although the mean amplitude, peak value, and area under the curve remained unchanged across conditions, a significant reduction in the trend coefficient, indicating motor unit recruitment over time, was observed with both music (biceps brachii: -10.39%, p < 0.001; brachioradialis: -9.40%, p < 0.001) and verbal encouragement (biceps brachii: -7.61%, p < 0.001; brachioradialis: -6.51%, p < 0.001) compared to the standard condition. For the trained participants, no significant differences were observed between conditions in terms of task duration and outcome measures related to muscle excitation and myoelectric manifestations of fatigue, suggesting the possible presence of a ceiling effect on motivation. These results highlight the important role of external motivational stimuli, such as music and verbal encouragement, in improving task performance in untrained subjects, probably through more effective and efficient recruitment of motor units.

Objective: This overview of systematic reviews (OoSRs) aimed, firstly, to systematically review, summarize, and appraise the findings of published systematic reviews with or without meta-analyses that investigate the effects of branched-chain amino acids (BCAA) on post-exercise recovery of muscle damage biomarkers, muscle soreness, and muscle performance. The secondary objective was to re-analyze and standardize the results of meta-analyses using the random-effects Hartung-Knapp-Sidik-Jonkman (HKSJ) method. Methods: The methodological quality of the reviews was assessed using A Measurement Tool to Assess Systematic Reviews 2.We searched on five databases ( i.e., PubMed, Web of Science, Scopus, SPORTDiscus, ProQuest) for systematic reviews with or without meta-analyses that investigated the effects of BCAA supplementation on the post-exercise recovery of muscle damage biomarkers, muscle soreness, and muscle performance. Results: Eleven systematic reviews (seven with meta-analyses) of individual studies were included. Evidence suggests BCAA ingestion attenuates creatine kinase (CK) levels (medium effects) and muscle soreness (small effects) immediately post-exercise and accelerates their recovery process, with trivial-to-large effects for CK levels and small-to-large effects for muscle soreness. BCAA supplementation has no effect on lactate dehydrogenase, myoglobin, and muscle performance recovery. The re-analyses with HKSJ method using the original data reported a slight change in results significance, concluding the same evidence as the original results. The major flaws found in the analyzed reviews were the absence of justification for excluding studies, and the lack of provision of sources of funding for primary studies and sources of conflict of interest and/or funding description. Conclusions: BCAA supplementation is an effective method to reduce post-exercise muscle damage biomarkers, particularly CK levels, and muscle soreness, with no effect on muscle performance. Future systematic reviews with/without meta-analyses, with greater methodological rigor, are needed.

In the biomedical field, the differentiation between sex and gender is crucial for enhancing the understanding of human health and personalizing medical treatments, particularly within the domain of orthopedics. This distinction, often overlooked or misunderstood, is vital for dissecting and treating musculoskeletal conditions effectively. This review delves into the sex- and gender-specific physiology of bones, cartilage, ligaments, and tendons, highlighting how hormonal differences impact the musculoskeletal system's structure and function, and exploring the physiopathology of orthopedic conditions from an epidemiological, molecular, and clinical perspective, shedding light on the discrepancies in disease manifestation across sexes. Examples such as the higher rates of deformities (adolescent idiopathic and adult degenerative scoliosis and hallux valgus) in females and osteoporosis in postmenopausal women illustrate the critical role of sex and gender in orthopedic health. Additionally, the review addresses the morbidity-mortality paradox, where women, despite appearing less healthy on frailty indexes, show lower mortality rates, highlighting the complex interplay between biological and social determinants of health. Injuries and chronic orthopedic conditions such osteoarthritis exhibit gender- and sex-specific prevalence and progression patterns, necessitating a nuanced approach to treatment that considers these differences to optimize outcomes. Moreover, the review underscores the importance of recognizing the unique needs of sexual minority and gender-diverse individuals in orthopedic care, emphasizing the impact of gender-affirming hormone therapy on aspects like bone health and perioperative risks. To foster advancements in sex- and gender-specific orthopedics, we advocate for the strategic disaggregation of data by sex and gender and the inclusion of "Sexual Orientation and Gender Identity" (SOGI) data in research and clinical practice. Such measures can enrich clinical insights, ensure tailored patient care, and promote inclusivity within orthopedic treatments, ultimately enhancing the precision and effectiveness of care for diverse patient populations. Integrating sex and gender considerations into orthopedic research and practice is paramount for addressing the complex and varied needs of patients. By embracing this comprehensive approach, orthopedic medicine can move towards more personalized, effective, and inclusive treatment strategies, thereby improving patient outcomes and advancing the field.

Aims: To determine the prevalence of dilated ventricles and concomitant high blood glucose measures., Methods: We retrieved blood glucose measures from the emergency department database and selected a subgroup of individuals having both the radiological marker Evans' index (EI) values and blood glucose measures., Results: Out of 1221 consecutive patients submitted to axial Computed Tomography scans, a blood glucose measure was detected in 841 individuals. 176 scans (21 %) showed an EI > 0.30. According to the blood glucose categorization, diabetic patients were 104 (12 %), 25 of them (24 %) were dilated (mean EI 0.33). The age difference between dilated and not-dilated ventricles is about ten years in not-diabetic participants, whereas it is five years in diabetic participants. The age difference between dilated and not-dilated ventricles is about 10 years in diabetic men, whereas it zero in diabetic women., Conclusions: Pathological ventricular enlargement is more frequent in men and in the elderly. In diabetic patients (especially women), the cerebral ventricles enlarge faster than in non-diabetic individuals. Age, sex, and diabetes may interact in determining how cerebral ventricle size changes over time, especially in diabetic women, making routine brain imaging advisable in these patients after the age of 70 years., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

Para-archery and para-shooting, two very popular adaptive shooting disciplines that have earned their place as major official events in the Paralympic Games, share some similarities, as well as distinctive features in terms of rules, physiological requirements, and equipment used. The International Paralympic Committee has a clear responsibility to ensure that all sports within its jurisdiction, including adaptive shooting, can achieve excellence in their respective fields. To achieve this, the conduct of well-designed studies and rigorous research is essential. Although some research has been conducted in this area, a comprehensive and systematic evaluation is still needed. Therefore, the present study aims to provide a thorough review and synthesis of existing research on adaptive shooting disciplines, identify strengths and gaps, and suggest future directions. Arksey and O'Malley's methodology is leveraged and enhanced with bibliometric and policy analyses to review literature on adaptive shooting. Databases like PubMed/MEDLINE, Scopus, Web of Science, OvidSP, and EMBASE were searched, focusing on studies in adaptive shooting disciplines and analysing these findings through a blend of thematic and statistical methods. Twenty-four studies totalling 483 para-athletes (299 para-shooters and 184 para-archers) are included in this scoping review, focusing on a range of aspects, including physiological responses (n = 9), research design and measurement methods for evidence-based classification (n = 6), biopsychosocial aspects (n = 3), development of new methods and technologies (n = 4), kinematic and biomechanical assessment (n = 1), and epidemiology of injuries (n = 1). Seven articles focused exclusively on para-archery, thirteen exclusively on para-shooting, and four on both para-archery and para-shooting. In conclusion, the available literature on adaptive shooting disciplines is still very limited, especially regarding para-archery compared to para-shooting. This highlights the need for further research in many key areas to ensure a better understanding of the different disciplines and to provide appropriate support for para-athletes. Future research in para-archery and para-shooting should focus on technological innovations, biomechanical studies, and psychological support to enhance athlete performance and accessibility. Addressing the imbalance between the two disciplines, along with injury prevention and global participation, can drive the sports towards greater inclusivity and equity for para-athletes worldwide.

Introduction: Dysphagia in post COVID-19 patients could be caused by several factors, including reduced pharyngolaryngeal coordination due to SARS-CoV-2 tropism to the central and/or peripheral nervous system. To our knowledge, this is the first reported case of COVID-19-related dysphagia successfully treated with botulinum toxin type A injection., Case Description: We report the case of a patient with severe oropharyngeal dysphagia due to COVID-19 confirmed by fibre endoscopy. As a result, the patient required an enteral feeding tube. After two months of traditional swallowing therapies, there was only limited improvement. An electrophysiologic evaluation of the cricopharyngeal muscle was performed and showed a normal inhibition of the cricopharyngeal muscle, followed by a hypertonic rebound. Based on this result, we decided to perform a unilateral laryngeal injection of botulinum toxin type A. After the injection, the patient's swallowing function improved significantly, allowing him to return to oral feeding., Discussion: Newly diagnosed oropharyngeal dysphagia was found in 35.3% of hospitalised patients with COVID-19. There are several possible causes of COVID-19-associated dysphagia, including stroke, encephalitis, critical illness neuropathy, Guillain-Barré syndrome and skeletal muscle injury. In our case, since stroke was excluded by brain MRI, cranial nerve injury was a possible explanation for the difficult recovery of swallowing despite daily swallowing therapy., Conclusion: We suggest that electrophysiology is a valid tool for the diagnosis and follow-up of patients with oropharyngeal dysphagia., Learning Points: SARS-CoV-2 tropism to the central and/or peripheral nervous system can cause dysphagia in post COVID-19 patients.An electrophysiologic approach is useful for the diagnosis and follow-up of patients with oropharyngeal dysphagia.A single botulinum toxin type A injection is a valid treatment option to improve the swallowing function in patients with post COVID-19 dysphagia., Competing Interests: Conflicts of Interests: The Authors declare that there are no competing interests., (© EFIM 2023.)

Muscle fatigue is a complex phenomenon that is influenced by the type of activity performed and often manifests as a decline in motor performance (mechanical failure). The purpose of our study was to investigate the compensatory strategies used to mitigate mechanical failure. A cohort of 21 swimmers underwent a front-crawl swimming task, which required the consistent maintenance of a constant speed for the maximum duration. The evaluation included three phases: non-fatigue, pre-mechanical failure, and mechanical failure. We quantified key kinematic metrics, including velocity, distance travelled, stroke frequency, stroke length, and stroke index. In addition, electromyographic (EMG) metrics, including the Root-Mean-Square amplitude and Mean Frequency of the EMG power spectrum, were obtained for 12 muscles to examine the electrical manifestations of muscle fatigue. Between the first and second phases, the athletes covered a distance of 919.38 ± 147.29 m at an average speed of 1.57 ± 0.08 m/s with an average muscle fatigue level of 12%. Almost all evaluated muscles showed a significant increase ( p < 0.001) in their EMG activity, except for the latissimus dorsi , which showed a 17% reduction (ES 0.906, p < 0.001) during the push phase of the stroke cycle. Kinematic parameters showed a 6% decrease in stroke length (ES 0.948, p < 0.001), which was counteracted by a 7% increase in stroke frequency (ES -0.931, p < 0.001). Notably, the stroke index also decreased by 6% (ES 0.965, p < 0.001). In the third phase, characterised by the loss of the ability to maintain the predetermined rhythm, both EMG and kinematic parameters showed reductions compared to the previous two phases. Swimmers employed common compensatory strategies for coping with fatigue; however, the ability to maintain a predetermined motor output proved to be limited at certain levels of fatigue and loss of swimming efficiency (Protocol ID: NCT06069440).

The aim of our study was to develop a methodology that uses the metronome to constrain the swimmers' stroke rate with the aim to monitor changes in stroke length (SL) during two different periods of the season. Thirteen young trained swimmers (15.7 ± 1.7 y) performed three 50 m front crawl time trials during pre-season (PRE) and after 2 months, during the in-season period (IN). They were asked: (I) to swim at their maximum intensity (NO-MET condition); (II) to synchronize their stroke with a metronome beat set to their preferred intra-stroke-interval (ISI) (100% condition, corresponding to 48 ± 0.7 cycles/min); (III) to synchronize their stroke with a metronome beat set at 5% higher than their preferred ISI (95% condition, corresponding to 51 ± 0.8 cycles/min). The outcome parameters used to evaluate the performance were ISI, SL and total time of 50 m (TT). In NO-MET condition, results showed that TT in IN improved with respect to PRE, but no changes in ISI and SL. In 100% condition, no differences were obtained between the imposed and the performed ISI, whilst in 95% condition, the performed ISI was lower than the metronome ISI, and lower than that in 100% condition. At last, when using the metronome, SL was higher during IN compared to PRE and SL was lower in the 95% condition compared to the 100% condition. Results indicate that the use of the metronome successfully allowed monitoring changes in SL during different periods of the season. This methodology provides valuable information to coaches and athletes to enhance their performance throughout the season., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (© 2023 Fassone, Bisio, Puce, Biggio, Tassara, Faelli, Ruggeri and Bove.)

Groin pain syndrome (GPS) is a prevalent issue in soccer. This study assessed the effectiveness of a new preventive protocol on GPS for youth soccer players. The protocol included targeted stretching and strengthening exercises for the adductor and core muscles from preseason to midseason. A questionnaire and two pain provocation tests were used for the evaluation. Mild GPS required positive results in at least two evaluations, while severe GPS was associated with pain incompatible with engagement in any activity confirmed by diagnostic ultrasound. Forty-two elite male athletes (aged 16.9 ± 0.7 years) participated in the study, with half of them assigned to the usual training (control group) and the remaining athletes undergoing the preventive protocol (treatment group) for 24 weeks. GPS rates were 14.3% (three diagnoses: two mild, one severe) in the treatment group and 28.6% (six diagnoses: three mild, three severe) in the control group. Toward the end of the season, three players, one from the treatment group and two from the control group had to stop playing due to severe GPS problems. In addition, one player in the control group stopped midseason. Even though the reduction in the risk of developing GPS was not significant (relative risk of 0.50 ([95%CI 0.14 to 1.74], p = 0.2759), the halved incidence of severe GPS and the increased muscle strength related to the treatment ( p = 0.0277) are encouraging data for future studies.

Hedonic well-being relates to how individuals experience and rate their lives. People with disabilities due to their pathology may more frequently suffer from anxiety and depressive disorders than their able-bodied counterparts. Sports participation is an essential way to cope with disability. On the other hand, compared with their able-bodied peers, para-athletes undergo a unique series of stressors. Little is known in terms of hedonic well-being in this specific population. We present the results of a multi-country survey of self-perceived hedonic well-being by para-athletes of different sports disciplines and a control group (disabled individuals not playing competitive sports), using the "Psychological General Well-Being Index" (PGWBI). We included 1,208 participants, aged 17.39 years, 58.4% male, 41.6% female, and 70.3% para-athletes. Para-athletes exhibited higher well-being than disabled people, for all domains of the PGWBI scale. The nature of disability/impairment was significant, with those with acquired disability reporting lower well-being. Those taking part in wheelchair basketball, para-athletics, and para-swimming competitions had a higher likelihood of reporting well-being, whereas those engaged in wheelchair rugby exhibited lower well-being compared with controls. This large-scale investigation can enable a better understanding of the self-perceived hedonic well-being of disabled people., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Puce, Biz, Cerchiaro, Scapinello, Giarrizzo, Trompetto, Marinelli, Trabelsi, Samanipour, Bragazzi and Ruggieri.)

The purpose of this investigation is to estimate the global disease burden attributable to low physical activity (PA) in 204 countries and territories from 1990 to 2019 by age, sex, and Socio-Demographic Index (SDI). Detailed information on global deaths and disability-adjusted life years (DALYs) attributable to low PA were collected from the Global Burden of Disease Study 2019. The ideal exposure scenario of PA was defined as 3000-4500 metabolic equivalent minutes per week and low PA was considered to be less than this threshold. Age-standardization was used to improve the comparison of rates across locations or between time periods. In 2019, low PA seems to contribute to 0.83 million [95% uncertainty interval (UI) 0.43 to 1.47] deaths and 15.75 million (95% UI 8.52 to 28.62) DALYs globally, an increase of 83.9% (95% UI 69.3 to 105.7) and 82.9% (95% UI 65.5 to 112.1) since 1990, respectively. The age-standardized rates of low-PA-related deaths and DALYs per 100,000 people in 2019 were 11.1 (95% UI 5.7 to 19.5) and 198.4 (95% UI 108.2 to 360.3), respectively. Of all age-standardized DALYs globally in 2019, 0.6% (95% UI 0.3 to 1.1) may be attributable to low PA. The association between SDI and the proportion of age-standardized DALYs attributable to low PA suggests that regions with the highest SDI largely decreased their proportions of age-standardized DALYs attributable to low PA during 1990-2019, while other regions tended to have increased proportions in the same timeframe. In 2019, the rates of low-PA-related deaths and DALYs tended to rise with increasing age in both sexes, with no differences between males and females in the age-standardized rates. An insufficient accumulation of PA across the globe occurs together with a considerable public health burden. Health initiatives to promote PA within different age groups and countries are urgently needed., Competing Interests: The authors declare that they have no competing interests. Author statement: All authors agreed to published version of the manuscript., (Copyright © Biology of Sport 2023.)

For a person with a disability, participating in sports activities and/or competitions can be a challenge for the immune system. The relationship between exercise and immunity response in disabled athletes is, indeed, extremely complex for several reasons, including (1) the chronic low-grade inflammatory and immunodepression-"secondary immune deficiency"-state imposed by the disability/impairment; (2) the impact of the disability on an array of variables, spanning from physical fitness to well-being, quality of life, sleep, and nutritional aspects, among others, which are known to mediate/modulate the effects of exercise on human health; (3) the variability of the parameters related to the exercise/physical activity (modality, frequency, intensity, duration, training versus competition, etc.); and (4) the intra- and inter-individual variability of the immunological response to exercise. In able-bodied athletes, previously published data described several exercise-induced changes affecting various immunological subsets and subpopulations, ranging from neutrophils to lymphocytes, and monocytes. Broadly, moderate intensity workout is accompanied by optimal immunity and resistance to infections such as upper respiratory tract infections (URTI) in athletes. Periods of intense training with insufficient recovery can cause a temporary state of immunosuppression, which should end with a few days of rest/recovery from exercise. Disabled athletes are relatively overlooked and understudied with respect to their able-bodied counterparts. Findings from the few studies available on paralympic and disabled athletes are here summarized and analyzed utilizing a narrative approach to review and determine the major features of the immunological and inflammatory responses to exercise in this specific population. Moreover, a few studies have reported behavioral, dietary, and training strategies that can be adopted to limit exercise-induced immunosuppression and reduce the risk of infection in people with disabilities. However, given the paucity of data and contrasting findings, future high-quality investigations on paralympic and disabled athletes are urgently needed.

By blocking the release of neurotransmitters, botulinum toxin A (BoNT-A) is an effective treatment for muscle over-activity and pain in stroke patients. BoNT-A has also been reported to increase passive range of motion (p-ROM), the decrease of which is mainly due to muscle shortening (i.e., muscle contracture). Although the mechanism of action of BoNT-A on p-ROM is far from understood, pain relief may be hypothesized to play a role. To test this hypothesis, a retrospective investigation of p-ROM and pain was conducted in post-stroke patients treated with BoNT-A for upper limb hypertonia. Among 70 stroke patients enrolled in the study, muscle tone (Modified Ashworth Scale), pathological postures, p-ROM, and pain during p-ROM assessment (Numeric Rating Scale, NRS) were investigated in elbow flexors (48 patients) and in finger flexors (64 patients), just before and 3-6 weeks after BoNT-A treatment. Before BoNT-A treatment, pathological postures of elbow flexion were found in all patients but one. A decreased elbow p-ROM was found in 18 patients (38%). Patients with decreased p-ROM had higher pain-NRS scores (5.08 ± 1.96, with a pain score ≥8 in 11% of cases) than patients with normal p-ROM (0.57 ± 1.36) ( p < 0.001). Similarly, pathological postures of finger flexion were found in all patients but two. A decreased finger p-ROM was found in 14 patients (22%). Pain was more intense in the 14 patients with decreased p-ROM (8.43 ± 1.74, with a pain score ≥ 8 in 86% of cases) than in the 50 patients with normal p-ROM (0.98 ± 1.89) ( p < 0.001). After BoNT-A treatment, muscle tone, pathological postures, and pain decreased in both elbow and finger flexors. In contrast, p-ROM increased only in finger flexors. The study discusses that pain plays a pivotal role in the increase in p-ROM observed after BoNT-A treatment.

Introduction: Despite the progress in the management of the pandemic caused by COVID-19, it is necessary to continue exploring and explaining how this situation affected the athlete population around the world to improve their circumstances and reduce the negative impact of changes in their lifestyle conditions that were necessitated due to the pandemic. The aim of this study was to analyze the moderating influence of physical activity (PA) and dietary habits on the impact of the COVID-19 pandemic experience on sleep quality in elite and amateur athletes., Materials and Methods: A total of 1,420 elite (40.1%) and amateur (59.9%) athletes (41% women; 59% men) from 14 different countries participated in a cross-sectional design study. Data were collected using a battery of questionnaires that identified sociodemographic data, sleep quality index, PA levels, dietary habits, and the athletes' perception of their experience during the COVID-19 pandemic. Means and standard deviations were calculated for each variable. The analysis of variances and the correlation between variables were carried out with non-parametric statistics. A simple moderation effect was calculated to analyze the interaction between PA or dietary habits on the perception of the COVID-19 experience effect on sleep quality in elite and amateur athletes., Results: The PA level of elite athletes was higher than amateur athletes during COVID-19 ( p < 0.001). However, the PA level of both categories of athletes was lower during COVID-19 than pre-COVID-19 ( p < 0.01). In addition, amateurs had a higher diet quality than elite athletes during the pandemic ( p = 0.014). The perception of the COVID-19 experience as controllable was significantly higher ( p = 0.020) among elite athletes. In addition, two moderating effects had significant interactions. For amateur athletes, the PA level moderated the effect of controllable COVID-19 experience on sleep quality [ F (3,777) = 3.05; p = 0.028], while for elite athletes, the same effect was moderated by dietary habits [ F (3,506) = 4.47, p = 0.004]., Conclusion: Elite athletes had different lifestyle behaviors compared to amateurs during the COVID-19 lockdown. Furthermore, the relevance of maintaining high levels of PA for amateurs and good quality dietary habits by elite athletes was noted by the moderating effect that both variables had on the influence of the controllable experience during the COVID-19 pandemic on sleep quality., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Taheri, Irandoust, Reynoso-Sánchez, Muñoz-Helú, Cruz-Morales, Torres-Ramírez, Mirmoezzi, Youzbashi, Mirakhori, Dergaa, Vancini, Mataruna-Dos-Santos, Korinna Zazueta-Beltrán, Zouhal, Morales-Beltrán, Soylu, Molgado-Sifuentes, González-Hernández, Hernández-Cruz, Bojorquez Castro, Kurt, Trabelsi, Chtourou, Seghatoleslami, López-Camacho, Mendoza-Baldenebro, Torabi, Ben Saad, Washif, Strahler, Guimarães-Mataruna, Lebaron, Shaabani Ezdini, Rezaei, Moshtagh, Yagin, Gülü, Esmaeili, Müller, Ammar, Scoditti, Garbarino, Puce, Bragazzi and Nobari.)

Background: Nowadays, digital gaming occupies a central position in the entertainment industry where it has developed into a cherished kind of entertainment in markets all over the world. In addition, it provides other sectors with various social and economic benefits. The Game Experience Questionnaire (GEQ) is a free, quantitative, and comprehensive self-report measure that was developed to assess the player game experience. Despite having been widely used by many research projects in the past, it has not been adapted into Arabic. Furthermore, several components of the scale proved problematic from a psychometric point of view. Therefore, a modified version of the scale is needed to measure the gaming experience of the Arab population., Objective: The aim of this study was to validate and examine the psychometrics of an adapted Arabic version of the GEQ in Tunisia., Methods: A total of 771 volunteer participants completed an online survey, which included an Arabic version of the GEQ, gaming data, and a sociodemographic questionnaire. Subjects were randomized in order to complete two phases of the study: exploratory and confirmatory. The exploratory data were acquired from 360 respondents whose mean age was 23.89 (SD 2.29) years. Out of 360 respondents, 111 (30.8%) were female and 249 (69.2%) were male. Confirmatory data were obtained from the remaining 411 subjects whose mean age was 21.94 (SD 1.80) years. Out of 411 subjects, 169 (41.1%) were female and 242 (58.9%) were male., Results: After the elimination of two items, the exploratory and the confirmatory factor analyses provided an adequate factor structure of the Arabic version of the GEQ. In addition, the internal consistency coefficients suggested the reliability of the instrument. Significant differences were revealed for three subcomponents: flow by age (η 2 =0.013, P=.002), gender (η 2 =0.007, P=.02), and game type (η 2 =0.03, P<.001). For competence (η 2 =0.01, P=.03) and immersion (η 2 =0.02, P=.01), significant differences were highlighted by the type of game. The discriminant and convergent validities of the instrument were supported by calculating the average variance extracted (AVE) and comparing the square roots of the AVE values to the correlation coefficients, respectively., Conclusions: The Arabic adapted version of the GEQ is valid and reliable and can be administered to measure the game experience in Arab countries., (©Mahmoud Rebhi, Mohamed Ben Aissa, Amayra Tannoubi, Mouna Saidane, Noomen Guelmami, Luca Puce, Wen Chen, Nasr Chalghaf, Fairouz Azaiez, Makrem Zghibi, Nicola Luigi Bragazzi. Originally published in JMIR Formative Research (https://formative.jmir.org), 20.03.2023.)

Para-rowing is a format of rowing practiced by people with different types of disabilities, thanks to adapted equipment set-ups and regulations. Para-rowing made its debut recently at the 2008 Paralympic Games. According to the mandate of the "International Paralympic Committee", para-rowers should be enabled to pursue sporting excellence. Therefore, rigorous research is needed in terms of well-designed, high-quality studies. To the best of our knowledge, there are no systematic appraisals of the body of scholarly evidence in the field of para-rowing. As such, a scoping review enhanced by bibliometric analyses was carried out to provide a comprehensive synthesis of knowledge related to para-rowing for the perusal of practitioners and athletes. By mining eighteen major databases, 17 studies were retained in the present review. The included studies were found to focus on a range of aspects involving health, the etiology of injuries (n = 5), psychological and physiological responses (n = 5), performance, biomechanical analysis (n = 4), and new analytical approaches for kinematic assessments and predictions of mechanical outputs in para-rowers (n = 3). The scholarly community on para-rowing consists of 78 researchers, 16 (20.51%) of whom are highly interconnected. The most prolific author was Smoljanović T., from Croatia, with three items/documents. In total, 93.6% of scholars have authored one single document. Topological features indicated a highly fragmented and dispersed, poorly connected community characterized by a high number of clusters and a low strength of connections. In terms of publication years, the first scholarly article dates back to 2008, with four articles (23.5%) published in the current year, showing an increasing interest in this para-sports discipline. Finally, gaps in current research on para-rowing were identified in terms of overlooked topics, including sports nutrition, doping, and psychological aspects in para-rowers other than those with visual impairment.

Global well-being (GWB) is a complex, multi-dimensional, and multi-faceted construct that can be explored from two different, but often overlapping, complementary perspectives: the subjective and the objective ones. The subjective perspective, in turn, is comprised of two dimensions: namely, the hedonic and the eudaimonic standpoints. Within the former dimension, researchers have developed the concept of subjective hedonic well-being (SHWB), whereas, within the latter, they have built the framework of psychological and social well-being (PSWB). Disabled people have poorer well-being due to their pathology and may more frequently suffer from anxiety and depressive disorders than their able-bodied counterparts. Sports participation is an essential way to cope with disability. On the other hand, compared with their able-bodied peers, athletes with disabilities and para-athletes undergo a unique series of stressors. Little is known in terms of hedonic and eudaimonic well-being and quality of life in this specific population. Here, we review the literature, with an emphasis on the current state-of-art and gaps in knowledge that need to be addressed by future research. High-quality, large-scale investigations are needed to have a better understanding of the self-perceived (hedonic) and objective (eudaimonic) well-being and quality of life of disabled people practicing sports, athletes with disabilities, and para-athletes., Competing Interests: PO, MY, GA, and RP were employed by Effective Basic Services (eBASE). The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Puce, Okwen, Yuh, Akah Ndum Okwen, Pambe Miong, Kong and Bragazzi.)

Background: In pursuit of quality teaching and learning, teachers seek the best method to provide their students with a positive educational atmosphere and the most appropriate learning conditions., Objectives: The purpose of this study is to compare the effects of the problem-solving method vs. the traditional method on motivation and learning during physical education courses., Methods: Fifty-three students ( M age 15 ± 0.1 years), in their 1st year of the Tunisian secondary education system, voluntarily participated in this study, and randomly assigned to a control or experimental group. Participants in the control group were taught using the traditional methods, whereas participants in the experimental group were taught using the problem-solving method. Both groups took part in a 10-hour experiment over 5 weeks. To measure students' situational motivation, a questionnaire was used to evaluate intrinsic motivation, identified regulation, external regulation, and amotivation during the first (T0) and the last sessions (T2). Additionally, the degree of students' learning was determined via video analyses, recorded at T0, the fifth (T1), and T2., Results: Motivational dimensions, including identified regulation and intrinsic motivation, were significantly greater (all p < 0.001) in the experimental vs. the control group. The students' motor engagement in learning situations, during which the learner, despite a degree of difficulty performs the motor activity with sufficient success, increased only in the experimental group ( p < 0.001). The waiting time in the experimental group decreased significantly at T1 and T2 vs. T0 (all p < 0.001), with lower values recorded in the experimental vs. the control group at the three-time points (all p < 0.001)., Conclusions: The problem-solving method is an efficient strategy for motor skills and performance enhancement, as well as motivation development during physical education courses., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer MJ declared a shared affiliation, with no collaboration, with the authors GE, NS, LM, and KT to the handling editor at the time of review., (Copyright © 2023 Ezeddine, Souissi, Masmoudi, Trabelsi, Puce, Clark, Bragazzi and Mrayah.)

Background: Aging often leads to cognitive function decline, sensory structure deterioration, and musculoskeletal system weakening. This impacts postural control during static and dynamic activities like walking, increasing the fall risk among the elderly. Older adults with mild cognitive impairment (MCI) face an elevated fall risk and cognitive decline, magnifying the public health concern., Objective: This study aimed to explore solutions by investigating the effects of a multi-component physical activity program on cognitive and motor functions in MCI patients., Methods: Twenty-three participants were enrolled in the study and assigned into two groups: an intervention group (n = 13; age = 85.7±5.5 years) and a control group (n = 9; age = 85±6.7 years). The study spanned two months, with participants engaging in three 60-minute weekly physical exercise sessions. The intervention focused on improving proprioception, muscle strength, and balance., Results: Results demonstrated significant enhancements in physical performance, fall risk reduction, and balance (p < 0.05). Various tests, including the timed up and go test, Unipedal Stance test, Tinetti test, Short Physical Performance Battery, and 6-minute walking test, indicated these improvements. Cognitive function was evaluated with the Mini-Mental State Examination, revealing non-significant progress (p > 0.05). Predictive models for outcomes were developed using linear regression analysis during the follow-up stage., Conclusions: This study underscores the effectiveness of a multi-component physical activity program encompassing balance, proprioception, and muscle-strengthening exercises as a non-pharmaceutical approach in improving balance skills and playing a key role in mitigating the risk of falls among old adults with MCI.

In patients with subacute stroke, task specific training (TST) has been shown to accelerate functional recovery of the upper limb. However, many patients do not have sufficient active extension of the fingers to perform this treatment. In these patients, here we propose a new rehabilitation technique in which TST is performed through a soft robotic hand (SoftHand-X). In short, the extension of the robotic fingers is controlled by the patient through his residual, albeit minimal, active extension of the fingers or wrist, while the patient was required to relax the muscles to achieve full flexion of the robotic fingers. TST with SoftHand-X was attempted in 27 subacute stroke patients unable to perform TST due to insufficient active extension of the fingers. Four patients (14.8%) were able to perform the proposed treatment (10 daily sessions of 60 min each). They reported an excellent level of participation. After the treatment, both clinical score of spasticity and its electromyographic correlate (stretch reflex) decreased. In subacute stroke patients, TST using SoftHand-X is a well-accepted treatment, resulting in a decrease of spasticity. At present, it can be applied only in a small proportion of the patients who cannot perform conventional TST, though extensions are possible., (© 2022. The Author(s).)

Background: Physical education teachers often experience stress and job disengagement., Objective: This study's aims were as follows: (1) to adapt in the Arabic language and test the reliability and the validity of the work-family conflict (WFC) and family-work conflict (FWC) scales, (2) to develop and assess the psychometric properties of work disengagement among physical education teachers, and (3) to evaluate an explanatory model by presenting the mediating role of perceived stress as a major influencing factor in work disengagement and job satisfaction., Methods: A total of 303 primary and secondary school physical education teachers, comprising 165 (54.5%) men and 138 (45.5%) women participated voluntarily in our study. The measuring instruments are the Work Disengagement Scale, the Perceived Stress Scale, the WFC scale, the FWC scale, and the 9-item Teacher of Physical Education Job Satisfaction Inventory., Results: The Arabic language versions of the WFC and FWC scales had reasonably adequate psychometric properties, which were justified by confirmatory factor analyses and by the measurement of reliability, convergent, and discriminant validity through the measurement model using SmartPLS software. Similarly, the structural model established with SmartPLS confirmed strong links of the concepts of FWC, WFC, the job satisfaction questionnaire, and perceived stress with work disengagement among teachers of physical education., Conclusions: There is a growing interest in helping teachers cope with the daily pressures of work and family. A positive organizational context is a context with clear values regarding work priorities, which constitutes the basis of a feeling of shared responsibility and professional support. Good conditions can act as protective factors reducing work stress and positively influencing personal well-being, work attitudes, work commitment, and professional efficiency. Additional research on teachers is needed to examine the relationship between perceived work stress and the role of families, along with the extent to which this association can have a significant impact on teachers' commitment to work., (©Nasr Chalghaf, Wen Chen, Amayra Tannoubi, Noomen Guelmami, Luca Puce, Noureddine Ben Said, Maher Ben Khalifa, Fairouz Azaiez, Nicola Luigi Bragazzi. Originally published in JMIR Formative Research (https://formative.jmir.org), 01.12.2022.)

Background and Objectives: Verbal encouragement (VE) can be used to enhance performance in several sports, even though no studies have been conducted among swimmers and only a few effects have been reported in elite athletes. Besides influencing motor performance, VE is also known to enhance the physical load, thus potentially increasing the probability of developing fatigue. With this in mind, this study aimed to explore the effects of VE in swimmers in order to fill in the knowledge gap concerning the aquatic environment. Materials and Methods: Each athlete swam a maximal 200 m freestyle trial under two different conditions: one trial with VE and the other without VE. The two main outcome measures were: (1) performance velocity (m/s); and (2) muscle fatigue, investigated by means of surface electromyography. Sixty swimmers were recruited, aged 18.63 ± 3.46 years (median 18 years), 28 men (47%), and 32 women (53%), with 7.03 ± 3.9 years of experience. Results: With VE, performance significantly improved in the swim trial (p < 0.001, effect size (ES) −0.95, large). When breaking the results down into the first half (first (0−100 m) vs. the second half (100−200 m)), the ES was large in the first part (−1.11), indicating an improvement in performance. This worsened, however, in the second part of the trial (ES 0.63). In the multivariate analysis, years of experience were found to be a significant predictor of the change in overall performance (p = 0.011). There was a significant increase in muscle fatigue induced by VE, overall, and during the second half, but not during the first half of the trial. Conclusions: The present study indicates that VE during a middle-distance event (200 m) increases performance most in swimmers with little experience. However, it has a negative impact on fatigue.

Paralympic powerlifting (PP), formerly known as "International Paralympic Committee" (IPC) powerlifting, is the format of powerlifting adapted for athletes with disabilities, and it differs from the version for able-bodied athletes in that it consists of bench press only. According to the mandate of the IPC, PP athletes should be enabled to achieve sporting excellence. As such, rigorous evidence is needed. However, to the best of our knowledge, there exists no systematic assessment of the body of scholarly evidence in the field of PP. Therefore, the present study was conducted to fill in this gap of knowledge, by conducting a scoping review of the literature enhanced by a bibliometrics analysis and by mining two major scholarly databases (MEDLINE via PubMed and Scopus). The aim was to provide a review/summary of the findings to date to help practitioners and athletes. Thirty-seven studies were retained in the present study. These covered the following thematic areas: (i) warm-up strategies ( n = 2); (ii) aspects of training ( n = 2); (iii) physiological aspects and responses ( n = 2); (iv) psychological aspects and responses ( n = 2); (v) biomechanics of bench press ( n = 8); (vi) recovery strategy ( n = 5); (vii) impact of the disability and type of disability ( n = 4); (viii) epidemiology of PP ( n = 6); and (ix) new analytical/statistical approaches for kinematics assessments, internal load monitoring, and predictions of mechanical outputs in strength exercises and in PP ( n = 6). Bibliometrics analysis of the PP-related scientific output revealed that, despite having already become a paralympic sports discipline in 1984, only in the last few years, PP has been attracting a lot of interest from the community of researchers, with the first scholarly contribution dating back to 2012, and with more than one-third of the scientific output being published this year (2022). As such, this scholarly discipline is quite recent and young. Moreover, the community dealing with this topic is poorly interconnected, with most authors contributing to just one article, and with one single author being a hub node of the author network. Distributions of the number of articles and the authors/co-authors were found to be highly asymmetrical, indicating that this research is still in its infancy and has great room as well as great potential to grow. Reflecting this, many research topics are also overlooked and underdeveloped, with the currently available evidence being based on a few studies.

Objectives: This study aimed to investigate the effects of Ramadan diurnal intermittent fasting (RDIF) on cognitive performance, sleep quality, daytime sleepiness, and insomnia in physically active and sedentary elderly individuals., Methods: A total of 58 participants (62.93 ± 3.99 years) were assigned to one of the following two groups: a sedentary group (control group) who observed Ramadan ( n = 32) and a physically active group ( n = 26) who continued to train while observing Ramadan. Participants were assessed 2 weeks before Ramadan and during the fourth week of Ramadan. On each occasion, participants completed a digital assessment of their cognitive performance and responded to the Pittsburgh sleep quality index (PSQI), the insomnia severity index (ISI) and the Epworth sleepiness scale (ESS) questionnaires to assess sleep parameters., Results: Compared to before Ramadan, performance in executive function ( p = 0.035), attention ( p = 0.005), inhibition ( p = 0.02), associative memory ( p = 0.041), and recognition memory ( p = 0.025) increased significantly during Ramadan in the physically active group. For the sedentary group, associative learning performance decreased ( p = 0.041), whilst performances in the remaining domains remained unchanged during Ramadan. Global PSQI, ISI, and ESS scores indicated both groups suffered from poor sleep quality and excessive daytime sleepiness, with significantly higher negative effects of RDIF observed in the sedentary group., Conclusion: Older adults who continue to train at least three times per week during Ramadan may improve their cognitive performance, despite the impairment of sleep quality. Future studies in older adults during Ramadan including objective measures of sleep (e.g., polysomnography, actigraphy) and brain function (e.g., functional magnetic resonance imaging) are warranted., Competing Interests: Authors JG and KB were employees in Neurotrack Technologies. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Boujelbane, Trabelsi, Jahrami, Masmoudi, Ammar, Khacharem, Boukhris, Puce, Garbarino, Scoditti, Khanfir, Msaad, Msaad, Akrout, Hakim, Bragazzi, Bryk, Glenn and Chtourou.)

Background: Cannabinoids may be useful to treat pain, epilepsy and spasticity, although they may bear an increased risk of cardiovascular events. This study aims to evaluate the cardiovascular safety of nabiximols, a cannabis-based drug, in patients with spasticity following stroke, thus presenting an increased cardiovascular risk., Methods: This is an ancillary study stemming from the SativexStroke trial: a randomized double-blind, placebo-controlled, crossover study aimed at assessing the effect of nabiximols on post-stroke spasticity. Patients were treated with nabiximols oromucosal spray or placebo and assessed before and after two phases of 1-month duration each. Only the phase with the active treatment was considered for each patient who completed the study. The average values of blood pressure (diastolic, systolic, differential) and heart rate from the first 5 days of the phase (lowest nabiximols dosage) were compared to the average values recorded during the last 5 days at the end of the phase (highest nabiximols dosage). Baseline comparisons between gender, stroke type and affected side and correlation between age and blood pressure and heart rate were performed. The study was registered with the EudraCT number 2016-001034-10., Results: Thirty-four patients completed the study and were included in the analysis. Thirty-one were taking antihypertensive drugs and, among these, 12 were taking beta-blockers. During the study, no arrhythmic events were recorded, blood pressure and heart rate did not show pathological fluctuations, and no cardiovascular or cerebrovascular events occurred. At baseline blood pressure and heart rate were comparable concerning gender, stroke type and affected side. A significant direct correlation emerged between differential blood pressure and age and an inverse correlation between diastolic blood pressure and age. No correlation emerged between systolic blood pressure or heart rate and age. Blood pressure and heart rate did not change during nabiximols treatment compared to the baseline condition., Conclusion: This ancillary study adds evidence that, in patients who already underwent a cerebrovascular accident, nabiximols does not determine significant blood pressure and heart rate variation or cardiovascular complications. These data support the cardiovascular safety of nabiximols, encouraging more extensive studies involving cannabinoids characterized by slow absorption rates., Competing Interests: CT received partial funding for other research projects from Almirall Group. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Rosa, Puce, Mori, Currà, Fattapposta, Porto, Bragazzi, Trompetto and Marinelli.)

Circadian rhythms are a series of endogenous autonomous oscillators that are generated by the molecular circadian clock which coordinates and synchronizes internal time with the external environment in a 24-h daily cycle (that can also be shorter or longer than 24 h). Besides daily rhythms, there exist as well other biological rhythms that have different time scales, including seasonal and annual rhythms. Circadian and other biological rhythms deeply permeate human life, at any level, spanning from the molecular, subcellular, cellular, tissue, and organismal level to environmental exposures, and behavioral lifestyles. Humans are immersed in what has been called the "circadian landscape," with circadian rhythms being highly pervasive and ubiquitous, and affecting every ecosystem on the planet, from plants to insects, fishes, birds, mammals, and other animals. Anthropogenic behaviors have been producing a cascading and compounding series of effects, including detrimental impacts on human health. However, the effects of climate change on sleep have been relatively overlooked. In the present narrative review paper, we wanted to offer a way to re-read/re-think sleep medicine from a planetary health perspective. Climate change, through a complex series of either direct or indirect mechanisms, including (i) pollution- and poor air quality-induced oxygen saturation variability/hypoxia, (ii) changes in light conditions and increases in the nighttime, (iii) fluctuating temperatures, warmer values, and heat due to extreme weather, and (iv) psychological distress imposed by disasters (like floods, wildfires, droughts, hurricanes, and infectious outbreaks by emerging and reemerging pathogens) may contribute to inducing mismatches between internal time and external environment, and disrupting sleep, causing poor sleep quantity and quality and sleep disorders, such as insomnia, and sleep-related breathing issues, among others. Climate change will generate relevant costs and impact more vulnerable populations in underserved areas, thus widening already existing global geographic, age-, sex-, and gender-related inequalities., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Bragazzi, Garbarino, Puce, Trompetto, Marinelli, Currà, Jahrami, Trabelsi, Mellado, Asgary, Wu and Kong.)

Background: Shear wave elastography (SWE) is a method for carrying out a quantitative assessment of the mechanical properties of soft tissues in terms of stiffness. In stroke survivors, the paretic muscles may develop hypertonia due to both neural-mediated mechanisms and structural alterations with consequent muscular fibrous-fatty remodeling., Methods: Fourteen adult patients with spastic dystonia following stroke were recruited. Muscle hypertonia was assessed using the modified Ashworth scale (MAS). Muscle activation was measured by surface electromyography (sEMG) with the selected muscle in shortened (spastic dystonia) and stretched (dynamic stretch reflex) positions. SWE was performed on a selected paretic muscle and on the contralateral non-paretic one to calculate shear wave velocities (SWV) along and across muscular fibers. The modified Heckmatt scale (MHS) pattern was also determined. All evaluations were performed shortly before BoNT-A injections (T0) and one month later (T1)., Results: All SWV on paretic muscles were higher than contralateral non-paretic ones ( p < 0.01). After BoNT-A injection, a significant reduction in MAS ( p = 0.0018), spastic dystonia ( p = 0.0043), and longitudinal SWE measurements, both in shortened ( p = 0.001) and in stretched muscular conditions ( p = 0.0029), was observed. No significant changes in SWV on non-paretic muscles were observed. Higher SWV resulted along the direction of muscular fibers vs. across them ( p = 0.001). No changes resulted from the MHS evaluations after BoNT-A. There was a positive correlation between MHS scores and SWV values while the muscle was in the shortened position, but not with spastic dystonia recorded by sEMG., Conclusions: This is the first study evaluating the effect of BoNT-A on muscle hypertonia following stroke, assessed by both SWE and sEMG. These findings support SWE as a useful method to disclose intrinsic muscular remodeling, independently of the effect of spastic dystonia, in particular, while muscles were assessed in a neutral position. SWE measurements of muscle stiffness cannot tell apart neural-mediated and intrinsic muscle hypertonia. Interestingly, when sEMG activity is very limited, as in spastic muscles kept in a shortened position, SWE can provide a measurement of stiffness due almost completely to intrinsic muscle changes. Alongside sEMG, SWE could aid clinicians in the assessment of responses to treatments., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Campanella, Corazza, Puce, Privitera, Pedrini, Mori, Boccuni, Turtulici, Trompetto and Marinelli.)

The human microbiota is comprised of more than 10-100 trillion microbial taxa and symbiotic cells. Two major human sites that are host to microbial communities are the gut and the skin. Physical exercise has favorable effects on the structure of human microbiota and metabolite production in sedentary subjects. Recently, the concept of "athletic microbiome" has been introduced. To the best of our knowledge, there exists no review specifically addressing the potential role of microbiomics for swimmers, since each sports discipline requires a specific set of techniques, training protocols, and interactions with the athletic infrastructure/facility. Therefore, to fill in this gap, the present scoping review was undertaken. Four studies were included, three focusing on the gut microbiome, and one addressing the skin microbiome. It was found that several exercise-related variables, such as training volume/intensity, impact the athlete's microbiome, and specifically the non-core/peripheral microbiome, in terms of its architecture/composition, richness, and diversity. Swimming-related power-/sprint- and endurance-oriented activities, acute bouts and chronic exercise, anaerobic/aerobic energy systems have a differential impact on the athlete's microbiome. Therefore, their microbiome can be utilized for different purposes, including talent identification, monitoring the effects of training methodologies, and devising ad hoc conditioning protocols, including dietary supplementation. Microbiomics can be exploited also for clinical purposes, assessing the effects of exposure to swimming pools and developing potential pharmacological strategies to counteract the insurgence of skin infections/inflammation, including acne. In conclusion, microbiomics appears to be a promising tool, even though current research is still limited, warranting, as such, further studies., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Puce, Hampton-Marcell, Trabelsi, Ammar, Chtourou, Boulares, Marinelli, Mori, Cotellessa, Currà, Trompetto and Bragazzi.)

Background: Nabiximols is a cannabis-based drug to treat spasticity-associated symptoms currently approved for patients with multiple sclerosis only. Cannabinoids are useful in an increasing number of medical conditions but may bear an increased risk for cardiovascular events. SativexStroke is a double-blind randomized placebo-controlled crossover monocentric clinical trial investigating the efficacy and safety of nabiximols in patients with spasticity following stroke., Methods: Patients were treated with nabiximols oromucosal spray or placebo and assessed before and after two phases of 1-month duration each. Cardiovascular safety was assessed before and during the trial. Primary endpoints were changes in spasticity numeric rating scale scores and electromyographic recording of the stretch reflex in affected wrist flexors. Secondary outcome measures were numeric rating scale scores for pain, sleep and bladder function, the number of daily spasms and clinical assessment of spasticity with the modified Ashworth scale. The study was registered with the EudraCT number 2016-001034-10., Results: Between May 2, 2018, and February 20, 2020, 41 patients entered the study. Seven patients did not complete the study, so 34 were included in the analysis. Two serious adverse events occurred, but none related to cardiovascular function. Primary and secondary efficacy outcome measures did not change from baseline during nabiximols treatment relative to placebo., Conclusion: This study suggests that nabiximols use is probably safe in stroke patients, therefore cannabinoid usefulness may be further investigated. The lack of nabiximols effect could be related to low pain levels in recruited patients or different spasticity mechanisms between post-stroke and multiple sclerosis patients. Similarly, a beneficial effect of nabiximols could have emerged if more patients with a higher level of spasticity at baseline were recruited., Clinical Trial Registration: https://www.clinicaltrialsregister.eu/ctr-search/trial/2016-001034-10/IT., Competing Interests: Unrelated to this project, Almirall Italia provided research funding to CT. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Marinelli, Puce, Mori, Leandri, Rosa, Currà, Fattapposta and Trompetto.)

In hypertonic muscles of patients with upper motor neuron syndrome (UMNS), investigation with surface electromyography (EMG) with the muscle in a shortened position and during passive muscle stretch allows to identify two patterns underlying hypertonia: spasticity and spastic dystonia. We recently observed in Para swimmers that the effect of fatigue on hypertonia can be different from subject to subject. Our goal was, therefore, to understand whether this divergent behavior may depend on the specific EMG pattern underlying hypertonia. We investigated eight UMNS Para swimmers (five men, mean age 23.25 ± 3.28 years), affected by cerebral palsy, who presented muscle hypertonia of knee flexors and extensors. Muscle tone was rated using the Modified Ashworth Scale (MAS). EMG patterns were investigated in rectus femoris (RF) and biceps femoris (BF) before and after two fatiguing motor tasks of increasing intensity. Before the fatiguing tasks, two subjects (#2 and 7) had spasticity and one subject (#5) had spastic dystonia in both RF and BF. Two subjects (#3 and 4) showed spasticity in RF and spastic dystonia in BF, whereas one subject (#1) had spasticity in RF and no EMG activity in BF. The remaining two subjects (#6 and 8) had spastic dystonia in RF and no EMG activity in BF. In all the 16 examined muscles, these EMG patterns persisted after the fatiguing tasks. Spastic dystonia increased ( p < 0.05), while spasticity did not change ( p > 0.05). MAS scores increased only in the muscles affected by spastic dystonia. Among the phenomena possibly underlying hypertonia, only spastic dystonia is fatigue-dependent. Technical staff and medical classifiers should be aware of this specificity, because, in athletes with spastic dystonia, intense and prolonged motor activity could negatively affect competitive performance, creating a situation of unfairness among Para athletes belonging to the same sports class., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Puce, Bragazzi, Currà, Marinelli, Mori, Cotellessa, Chamari, Ponzano, Samanipour, Nikolaidis, Biz, Ruggieri and Trompetto.)

Background and Objectives: Table tennis represents one of the fastest ball games in the world and, as such, is characterized by unique physiological demands. Despite its popularity, there is a dearth of data related to table-tennis-related risk factors and injuries. Therefore, the present review was conducted to fill in this gap of knowledge. Material and Methods: The present review was designed as a scoping review. Eleven online databases were searched with no language/date limitations. Results: Forty-two investigations were retained in the present review. These studies indicated that tenosynovitis, benign muscle injuries, strains, and sprains were the most common injury types. In order, the most commonly affected anatomical regions were the lower limb, shoulder, spine, knee, upper limb, and trunk. When comparing the injury occurrence between training and competition, the results were contradictory. National/international athletes had higher indices of injury than regional players, even though other investigations failed to replicate such findings. According to some scholars, there was a difference between female and male athletes: in females, more injuries involved the upper limbs when compared to men who had more injuries to the lower limbs, while other studies did not find differences in terms of gender. Conclusions: Table tennis is generally considered at lower risk for injuries than other sports. However, the present scoping review showed that injuries can occur and affect a variety of anatomic regions. Sports scientists/physicians could utilize the information contained in the current review for devising ad hoc programs to adopt an effective/appropriate prevention strategy and to monitor table tennis players' training load and to achieve maximal fitness, as these will reduce the risk of injuries. However, most of the studies included in our scoping review are methodologically weak or of low-to-moderate evidence, being anecdotal or clinical case reports/case series, warranting caution when interpreting our findings and, above all, further high-quality research in the field is urgently needed.

Background: To examine mental health during COVID-19 peaks, lockdown, and times of curfew, many studies have used the LPA/LCA person-centered approach to uncover and explore unobserved groups. However, the majority of research has focused only on negative psychological concepts to explain mental health. In this paper, we take another perspective to explore mental health. In addition, the study focuses on a period of peak decline in the COVID-19 pandemic., Objective: The present paper aim (a) empirically identifies different profiles among a cohort of Facebook users in Tunisia based on positive factors of mental health using a person-centered approach, (b) outline identified profiles across sociodemographic, internet use, and physical activity, and (c) establish predictors of these profiles., Methods: Cross-sectional data were collected through an online survey among 950 Facebook users were female ( n = 499; 52.53%) and male ( n = 451; 47.47) with an average age =31.30 ± 9.42. Subjects filled Arabic version of Satisfaction with Life Scale, Scale of Happiness (SWLS), Gratitude Questionnaire (GQ-6), International Physical Activity Questionnaire (IPAQ), and the Spirituel Well-Being Scale (SWBS) ., Results: The LPA results revealed three clusters. The first cluster ( n = 489, 51,47%) contains individuals who have low scores on the positive psychology scales. The second cluster ( n = 357, 37,58%) contained individuals with moderate positive psychology scores. However, a third cluster ( n = 104, 10,95%) had high positive psychology scores. The selected variables in the model were put to a comparison test to ensure that the classification solution was adequate. Subsequently, the clusters were compared for the variables of socio-demographics, use of the internet for entertainment and physical activity, the results showed significant differences for gender (low mental well-being for the female gender), socio-economic level (low for the low-income class), and physical activity (low mental well-being for the non-exerciser). However, no significant differences were found for the variables age, location, and use of the Internet for entertainment., Conclusion: Our results complement person-centered studies (LPA/LCA) related to the COVID-19 pandemic and can serve researchers and mental health practitioners in both diagnostic and intervention phases for the public. In addition, the GQ6 scale is a valid and reliable tool that can be administered to measure gratitude for culturally similar populations., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer NR declared a shared affiliation with the author LP at the time of the review., (Copyright © 2022 Guelmami, Tannoubi, Chalghaf, Saidane, Kong, Puce, Fairouz, Bragazzi and Alroobaea.)

Cardiological disorders contribute to a significant portion of the global burden of disease. Cardiology can benefit from Big Data, which are generated and released by different sources and channels, like epidemiological surveys, national registries, electronic clinical records, claims-based databases (epidemiological Big Data), wet-lab, and next-generation sequencing (molecular Big Data), smartphones, smartwatches, and other mobile devices, sensors and wearable technologies, imaging techniques (computational Big Data), non-conventional data streams such as social networks, and web queries (digital Big Data), among others. Big Data is increasingly having a more and more relevant role, being highly ubiquitous and pervasive in contemporary society and paving the way for new, unprecedented perspectives in biomedicine, including cardiology. Big Data can be a real paradigm shift that revolutionizes cardiological practice and clinical research. However, some methodological issues should be properly addressed (like recording and association biases) and some ethical issues should be considered (such as privacy). Therefore, further research in the field is warranted., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Dai, Younis, Kong, Puce, Jabbour, Yuan and Bragazzi.)

Aims: Our study aimed to develop a two-factor self-administered orthogonal questionnaire to assess the experience of perceived physical inactivity, to test its psychometric properties, to confirm its relationships with fear of COVID-19, and finally, with perceived stress during the pandemic., Methods: A total of 481 Tunisian subjects collected in several cities, aged from 16 to 67 years with a mean age = 32.48 ± 9.46, and of both sexes participate in our study with (male: 51.8%) and (female: 48.2%), divided according to the level of study into three categories. All subjects voluntarily answered the PIPES questionnaire, the IPAQ scale, the COVID-19 fear scale and the PSS-10 test., Results: The results of the exploratory and confirmatory factor analysis supported the robustness of the tool measure. In addition, examination of configurational, metric, scalar, and strict invariance supported the equivalence of the structure by gender and educational level. Concurrent validity was established by the positive association of a negative perception of physical inactivity with scores measured by the IPAQ scale and a negative association with scores of COVID-19 fear and perceived stress. Whereas, a positive perception of physical inactivity from the COVID-19 scale was negatively associated with the IPAQ and positively associated with fear of COVID-19 and perceived stress., Conclusion: The PIPES-10 scale can be used to measure the perception of physical inactivity in different situations., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Guelmami, Chalghaf, Tannoubi, Puce, Azaiez and Bragazzi.)

Drafting in swimming is a tactic in which an athlete (drafter) swims in the wave of another athlete (leader). Our aim was to compare the effects of this tactic on the drafter, as far as muscle fatigue, muscle activity, and swimming efficiency are concerned. Fifteen drafters performed three 200 m front crawl trials at a controlled submaximal pace in three configurations: Behind Drafting (BD), Lateral Drafting (LD), and Free Swimming (FS). Muscle fatigue, muscle activity, and swimming efficiency were obtained by surface electromyography (EMG) and video analysis from flexor carpi radialis, triceps brachii, latissimus dorsi, and rectus femoris muscles. The outcome measures were: time slope of Mean Frequency (MNF), for muscle fatigue; time slope of Root Mean Square (RMS), for muscle activity; and Stroke Index (SI) for swimming efficiency. Negative variations of MNF were 5.1 ± 1.7%, 6.6 ± 4.1%, and 11.1 ± 2.7% in BD, LD, and FS, respectively. Statistical significance was found for all cases except for the rectus femoris. Positive variations of RMS were 3.4 ± 1.2%, 4.7 ± 2.7%, and 7.8 ± 4.6% in BD, LD, and FS, respectively. Statistical significance was found only for the slopes of latissimus dorsi in FS and LD. The largest mean in SI was measured in the BD (2.01 m 2 /s), while the smallest was measured in the FS (1.86 m 2 /s). BD was found to be the best swimming configuration, in terms of lower muscle fatigue and higher swimming efficiency. Also, LD resulted to be advantageous with respect to FS., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Puce, Chamari, Marinelli, Mori, Bove, Faelli, Fassone, Cotellessa, Bragazzi and Trompetto.)

Background: Grit is a key concept in positive psychology and educational science. The construct measures two related constructs that are interest and effort. Several instruments have been developed to measure this construct in professional and educational contexts, but no tools have been developed considering specific contexts such as physical education and sport., Objectives: The objective of this study is to develop and test a measurement scale to assess Grit in the context of physical education and sport., Methods: Two exploratory (Phase 1) and confirmatory (Phase 2) samples were administered the 16-item PE-Grit scale in Arabic. In addition, the confirmatory sample also was administered the R-SPQ-2F two-factor learning approaches scale. The factor structure was examined first by exploratory factor analysis on the first sample and then by confirmatory factor analysis on the second sample. Reliability testing was performed by checking internal consistency simultaneously by the three indices: McDonald's ω, Cronbach's α and Gutmann's λ6. Concurrent validity was checked by Pearson's correlation between the PE-Grit and the two dimensions of the SPQ-2F., Results: After the exploratory factor analysis, which identified the factors and gave a preliminary validation of the designed instrument, confirmatory factor analysis was performed on three hierarchical models to be able to identify the best fitting model. A third-order hierarchical model with two physical and academic components each formed by interest and effort presented the best fit indices: chi X2 = 192.95 ( p < 0.01), and the X2/DF = 1.36; GFI = 0.99; AGFI = 0.99; CFI and TLI close to 1; RMSEA = 0.025. In addition, McDonald's ω, internal consistency, and Gutmann's λ6 ranged from 0.78 to 0.86 for all four scale dimensions., Conclusion: The PE-Grit scale displays adequate factor structure, good reliability, and acceptable concurrent validity and can be administered to assess Grit in physical education and sport students., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Guelmami, Chalghaf, Tannoubi, Puce, Azaiez and Bragazzi.)

Together with environment and experience (that is to say, diet and training), the biological and genetic make-up of an athlete plays a major role in exercise physiology. Sports genomics has shown, indeed, that some DNA single nucleotide polymorphisms (SNPs) can be associated with athlete performance and level (such as elite/world-class athletic status), having an impact on physical activity behavior, endurance, strength, power, speed, flexibility, energetic expenditure, neuromuscular coordination, metabolic and cardio-respiratory fitness, among others, as well as with psychological traits. Athletic phenotype is complex and depends on the combination of different traits and characteristics: as such, it requires a "complex science," like that of metadata and multi-OMICS profiles. Several projects and trials (like ELITE, GAMES, Gene SMART, GENESIS, and POWERGENE) are aimed at discovering genomics-based biomarkers with an adequate predictive power. Sports genomics could enable to optimize and maximize physical performance, as well as it could predict the risk of sports-related injuries. Exercise has a profound impact on proteome too. Proteomics can assess both from a qualitative and quantitative point of view the modifications induced by training. Recently, scholars have assessed the epigenetics changes in athletes. Summarizing, the different omics specialties seem to converge in a unique approach, termed sportomics or athlomics and defined as a "holistic and top-down," "non-hypothesis-driven research on an individual's metabolite changes during sports and exercise" (the Athlome Project Consortium and the Santorini Declaration) Not only sportomics includes metabonomics/metabolomics, but relying on the athlete's biological passport or profile, it would enable the systematic study of sports-induced changes and effects at any level (genome, transcriptome, proteome, etc.). However, the wealth of data is so huge and massive and heterogenous that new computational algorithms and protocols are needed, more computational power is required as well as new strategies for properly and effectively combining and integrating data., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Sellami, Elrayess, Puce and Bragazzi.)

This observational study aimed at investigating pain in stroke patients with upper limb spastic dystonia. Forty-one consecutive patients were enrolled. A 0-10 numeric rating scale was used to evaluate pain at rest and during muscle tone assessment. Patients were asked to indicate the most painful joint at passive mobilization (shoulder, elbow, wrist-fingers). The DN4 questionnaire was administered to disclose neuropathic pain. All patients were assessed just before and 1 month after incobotulinumtoxin-A treatment. Pain was present in 22 patients, worsened or triggered by passive muscle stretching. DN4 scored < 4 in 20 patients. The most painful joints were wrist-fingers in 12 patients, elbow in 5 patients and shoulder in the remaining 5 patients. Both elbow and wrist-fingers pain correlated with muscle tone. BoNT-A treatment reduced pain in all the joints, including the shoulder. We discussed that nociceptive pain is present in a vast proportion of patients with upper limb spastic dystonia. BoNT-A treatment reduced both spastic dystonia and pain in all the joints but the shoulder, where the effect on pain could be mediated by the reduction of pathological postures involving the other joints.

Background: Information on prevalence, pathophysiology, and clinical assessment of paratonia are scarce. In a previous study, we suggested that surface electromyography (EMG) can be used to assess paratonia., Objective: To assess clinical and EMG features of paratonia in both patients with cognitive impairment and healthy subjects., Methods: We examined 18 patients with Alzheimer's disease (AD), 21 patients with mild cognitive impairment (MCI), 30 healthy seniors (seniors), and 30 healthy juniors (juniors). Paratonia was assessed using the "Paratonia Scale". EMG bursts were recorded from biceps and triceps during manually applied passive movements of elbow joint. Continuous (sinusoidal) and discontinuous (linear) movements were applied at 2 different velocities (fast and slow)., Results: In comparison to juniors, seniors had higher clinical scores. In comparison to seniors, AD had higher oppositional scores, while MCI had higher facilitatory scores. EMG activity during passive movements correlated with paratonia clinical scores, was velocity-dependent and increased with movement repetition, most effectively for sinusoidal movements. Similar EMG activity was detected in not paratonic muscles., Conclusion: Paratonia increases with normal aging and cognitive decline progression. While facilitatory paratonia is due to involuntary contraction of the shortening muscle, oppositional paratonia is due, at least partially, to involuntary contraction of the lengthening muscle. Most characteristic feature of this muscle contraction is the progressive increase with movement repetition, that helps distinguish oppositional paratonia from spasticity and rigidity. A similar EMG activity is detected in not paratonic muscles, showing that, during tone assessment, the descending motor system is incompletely inactivated also in normotonic muscles.

Day-to-day walking-related activities frequently involve the simultaneous performance of two or more tasks (i.e., dual task). Dual task ability is influenced by higher order cognitive and cortical control mechanisms. Recently, it has been shown that the concomitant execution of an attention-demanding task affected postural control in subject with cervical dystonia (CD). However, no study has investigated whether dual tasking might deteriorate gait performance in CD patients. To investigate whether adding a concomitant motor and cognitive tasks could affect walking performance in CD subjects.17 CD patients and 19 healthy subjects (HS) participated in this pilot case-control study. Gait performance was evaluated during four walking tasks: usual, fast, cognitive dual task and obstacle negotiation. Spatiotemporal parameters, dual-task cost and coefficients of variability (CV%) were measured by GaitRite ® and were used to detect differences between groups. Balance performance was also assessed with Mini-BEST and Four Step Square tests. In CD participants, correlation analysis was computed between gait parameters and clinical data. Significant differences in complex gait and balance performance were found between groups. CD patients showed lower speed, longer stance time and higher CV% and dual-task cost compared to HS. In CD, altered gait parameters correlated with balance performance and were not associated with clinical features of CD. Our findings suggest that complex walking performance is impaired in patients with CD and that balance and gait deficits might be related., (© 2021. The Author(s).)

This study compared the effects of two breathing conditions during the freestyle turn approach phase in swimmers. Thirty-four prepubertal swimmers (mean ± SD: 10.59 ± 0.97 years) were divided into two groups: No Breath (NB), not breathing at the last stroke, and Breath Stroke (BS). Swimmers performed three turns with 5 min of rest between the repetitions. Kinematic parameters were recorded with two underwater and two surface cameras. Total turn time (NB: 9.31 ± 1.34 s; BS: 10.31 ± 1.80 s; p = 0.049), swim-in time (NB: 3.89 ± 0.63 s; BS 4.50 ± 0.79 s; p = 0.02) and rotation time (NB: 2.42 ± 0.29 s; BS: 3.03 ± 0.41 s; p = 0.0001) were significantly shorter and swim-in distance [NB: 0.70 (0.58,0.77) m; BS: 0.47 (0.34,0.55) m; p = 0.0001], glide distance (NB: 1.06 ± 0.21 m; BS: 0.70 ± 0.20 m; p = 0.0001) and surfacing distance [NB: 1.79 (1.19,2.24) m; BS: 1.18 (0.82,1.79) m; p = 0.043] were significantly longer in NB than in BS. Moreover, speed-in (NB: 1.04 ± 0.14 m/s; BS: 0.93 ± 0.14 m/s; p = 0.031) and push-off speed (NB: 2.52 ± 0.30 m/s; BS: 1.23 ± 0.20 m/s; p = 0.001) were significantly higher in NB than in BS. Swim-in time was positively and negatively correlated with rotation time and glide distance, respectively, whilst negative relationships between total turn time and swim-in distance, total turn time and surfacing distance and total turn time and speed-in were found. Our study showed that in prepubertal swimmers not breathing at the last stroke during the approach phase positively affected kinematic parameters of the turn, allowing to approach the wall faster, rotate the body quicker, increase push-off speed, reduce turn execution time, thus improving overall turn performance., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Faelli, Strassera, Ottobrini, Ferrando, Bisio, Puce, Panascì, Lagorio, Ruggeri and Bove.)