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Objective: To review the achievements of cardiac exercise rehabilitation programs retrospectively and to identify continuing challenges to their success. Methods: A review of files accumulated while working with the Toronto Rehabilitation Center, updated by articles identified by PUB-MED, OVID, and Google Scholar through February 2019. Results: After the early lead of Israeli physicians, cardiac rehabilitation began in Ontario during the 1960s and quickly attracted a large case load. Recurrence rates of the patients recruited were low relative to those receiving standard medical treatment, even after allowing for differences in risk factors at entry to programs. Controlled trials began but were individually of insufficient in size to show a significant reduction in recurrences or mortality. Subsequently, multiple meta-analyses demonstrated a 20% to 25% reduction of all-cause and cardiac mortality over the first few years of follow-up in patients who persisted with their rehabilitation. Compliance continued a problem at many centers, but special features of the Toronto cardiac rehabilitation program sustained a compliance of 82.8% over 3 years. Although vigorous exercise increased the immediate risks of a recurrence 5- to 10-fold, this was more than offset by the long-term benefits of enhanced physical condition, and cardiac deaths were a rarity during either supervised or home-based exercise sessions. About a half of patients developed a depression immediately after infarction, but if encouraged to persist with prescribed exercise, their quality of life progressively improved. Among the wide variety of mechanisms underlying the benefits of exercise, gains of aerobic power seemed particularly important. With sustained training, the physical condition of some younger patients progressed to the point of participating successfully in marathon events. Older patients also benefited from sustained training, but for them, optimal results were likely associated with less rigorous physical demands. Conclusions: Research conducted in Toronto and elsewhere has established the benefits of exercise-centered cardiac rehabilitation. However, there remains a need to define the optimum timing of program onset, and the frequency, intensity, and duration of supervised training sessions. Return to blue-collar occupations also needs to be boosted, and the limited participation of eligible patients in available programs remains a continuing challenge. [ABSTRACT FROM AUTHOR]

Autonomic dysreflexia is a common response to painful stimuli following high level spinal injuries. Loss of normal control of sympathetic reflexes leads to large increases in blood pressure, accompanied by headache and occasional more dangerous sequelae. Although now officially banned, intentional dysreflexia (“boosting”) is still exploited by some competitors to gain an unfair advantage. It is thus important to consider physiological mechanisms, consequences for health and performance, and methods of controlling this abuse. Boosters perceive the practice as frequent, performance enhancing, and of low immediate risk. Effective methods of eliminating the practice may include more stringent control of competitors, evaluating and publicizing short-and long-term risks, and countering arguments that boosting is an ethically acceptable method of restoring a normal physiological response. [ABSTRACT FROM AUTHOR]

This paper offers a brief response to the article of Bouffard (2001), which in itself was a reaction to two earlier papers published by the present author (Shephard, 1998, 1999). Bouffard makes a vigorous attack on his perceptions of my observations concerning the use of jargon, the primacy of the scientific method, and postmodernism. Unfortunately, his perceptions of my arguments are not always substantiated by a careful reading of the text. Many of the world's social ills are rashly attributed uniquely to rationalism. No viable alternatives to the scientific method are suggested, and self-criticism of the postmodern approach is less than optimal. Nevertheless, the paper is to be welcomed, both as a challenge to continuing perfection of evidence-based science and as providing an insight into the thinking of those who espouse the postmodernist philosophy. [ABSTRACT FROM AUTHOR]

This paper examines the postmodernist critique of the scientific method in the specific context of adapted physical activity. Particular assumptions identified include (at that truth must be approached through testing hypotheses, with acceptance of the most plausible explanation, (b) that underlying laws have general (if not universal) application, and (c) that the observer approaches an experiment free of bias and without interacting with the subject. Post modernists also argue, less convincingly, that users of the scientific method are committed to reductionism, are tyrannized by the mean, and are unable to quantitate important components of disability. The overall critique raises consciousness regarding the limitations of scientific methodology and points to ways this methodology can be improved. But too often, postmodernists offer few viable alternatives to the scientific method. Too often, those who espouse postmodernism resort to convoluted semantics, using poorly defined words of uncertain etymology. Such an approach does little to help the human condition and should be rejected as a new gnostic heresy. [ABSTRACT FROM AUTHOR]

A quantitative hypothetico-deductive approach has continued to contribute greatly to advances in biological and medical science. Quantitative methods are adopted over other approaches primarily because they contribute the most new knowledge about biological processes. Nevertheless, investigators make many assumptions when testing a biological hypothesis quantitatively. These assumptions may become invalid unless experiments are designed with great care. Problems arise in relation to formulating appropriate hypotheses, using volunteer samples, controlling the experimental intervention and potentially interfering behaviors, reaching an acceptable level of proof, excluding alternative hypotheses, and generalizing findings beyond the immediate experimental sample. When biologists are aware of these issues, they can take appropriate countermeasures and reach valid conclusions. However, the issues become more critical and resolution is less clear-cut when the same methods are extended from biology to psychology and the social sciences, and from general to special populations. In such situations, case studies and single-subject designs may have continuing relevance. [ABSTRACT FROM AUTHOR]

An arm ergometer analog of the Canadian Aerobic Fitness Test (CAFT) has been proposed for subjects with impairments of mobility (Longmuir & Shephard, 1995). Because of muscle weakness or spasm, only 63% of the adults concerned could maintain the required cadence in the original test version. Thus, in the present study it was hypothesized that a reduced crank loading would yield a higher success rate. In a sample of 35 adults with mobility impairment, 82% were able to complete at least one stage of the modified lest. Difficulty was encountered mainly by persons with cerebral palsy or multiple sclerosis. The revised protocol had a high (r = .97) 1-week test/retest reliability, with no test/retest bias except that subjects with brain lesions scored somewhat higher at their second assessment. A scaled prediction of peak oxygen intake using the standard CAFT equation agreed closely with direct arm ergometer determinations of it. The modified test showed a mean discrepancy ±SD of 0.1 ± 4.8 ml/[kg · min). Further validation is needed, but the current analog of the standard CAFT appears to be useful for many with mobility impairments. [ABSTRACT FROM AUTHOR]

The Arm CAFT is a simple submaximal arm ergometer lest for subjects with mobility disabilities, designed to match the Canadian Aerobic Fitness Test (CAFT) in both administration and interpretation. It is here evaluated relative to direct arm ergometer measurements of peak oxygen intake in 41 men and women with mobility disabilities, aged 20-60, who were attending an "integrated" sports facility. Peak oxygen intake was predicted using the original CAFT equation, but the oxygen cost of arm ergometer test stages was substituted and predictions were scaled downward by 70/100 to allow for the lower peak aerobic power of the upper limbs. In 16 subjects who maintained cranking cadence, predictions were reliable over 1 week, with a small increase of score at the second test. Although the Arm CAFT protocol is reliable and free of bias, it has only a limited validity, and only a minority of the stronger individuals with mobility disabilities can sustain the required cranking rhythm. [ABSTRACT FROM AUTHOR]

Since 2013, this journal has promoted the publication of thematic reviews (Taylor in Eur J Appl Physiol 113:1634, 2013), where leading groups were invited to review the critical literature within each of several sub-topics. The current theme is historically based, and is focussed on estimating the metabolic rate in humans. This review charts the development of our understanding of those methods, from the discovery of oxygen and carbon dioxide, to the introduction of highly sophisticated modern apparatus to examine the composition of expired gas and determine respiratory minute volume. An historical timeline links the six thematic vignettes on this theme. Modern advances have greatly enhanced data collection without significant decrements in measurement accuracy. At the same time, however, conceptual errors, particularly steady-state requirements, are too often ignored. Indeed, it is recognised that we often neglect the past, leading to errors in research design, experimental observations and data interpretation, and this appears to be increasingly prevalent within the open-access literature. Accordingly, the Editorial Board, in recognition of a widening gap between our experimental foundations and contemporary research, embarked on developing a number of thematic review series, of which this series is the first. The intent of each accompanying overview is to introduce and illuminate seminal investigations that led to significant scientific or intellectual breakthroughs, and to thereby whet the appetite of readers to delve more deeply into the historical literature; for it is only when the foundations are understood that we can best understand where we are now, and in which directions we should head. [ABSTRACT FROM AUTHOR]

Objective: To compare findings from several recent meta-analyses showing a reduced risk of gastric and esophageal cancers in physically active individuals, to assess the magnitude of this benefit, and to seek information on potential underlying mechanisms. Data Sources: A comprehensive search of Ovid/Medline from 1996 to February 2016, using the terms physical activity or exercise or training and esophageal or gastric cancer, and supplementing the articles identified by material from references lists and personal files. Main Results: Moderate-to-vigorous physical activity is associated with a 20% to 30% reduction in the risk of gastroesophageal adenocarcinomas, with a significant dose/response relationship. Benefit is greater in women than in men, and greater for noncardia than for cardia or esophageal tumors. Mechanisms could include a reduction of visceral fat (with a lesser production of cancer promoting hormones and reduced gastroesophageal reflux) and/or a lesser likelihood of smoking and excessive alcohol consumption. Physical activity does not protect against Helicobacter pylori infections or gastric ulceration, but mechanisms related to the impact of exercise on immune function, antioxidant mechanisms, and gastroesophageal reflux remain to be explored. Conclusions: Regular, moderate-to-vigorous physical activity is associated with a clinically significant reduction in the risk of gastroesophageal adenocarcinomas, but mechanisms are as yet unclear, and a causal relationship remains to be proven. [ABSTRACT FROM AUTHOR]

Objectives To examine dose/response relationships between habitual physical activity and bone health in the elderly. Design Longitudinal. Setting Community of Nakanojo. Participants Community-living Japanese aged 65 to 84 (212 men, 284 women). Measurements Daily 24-h pedometer/accelerometer data were collected continuously for 5 years. A quantitative calcaneal osteosonic index ( OSI) was determined annually. Results Year-end OSI values were higher in those with greater daily step counts and especially a greater duration of activity >3 metabolic equivalents ( METs). However, after controlling for baseline OSI, age and body mass, final OSI values were not significantly greater in the fourth than in the third activity quartile, where men and women, respectively, took means of 7,700 and 7,500 steps/day and/or exercised at an intensity >3 METs for means of 19 and 17 min/day. A multivariate-adjusted proportional hazards model predicted that the OSI values of men and women were, respectively, 2.6 (1.4-4.4) and 3.3 (2.1-5.2) and/or 2.8 (1.5-5.6) and 3.9 (2.4-6.7) times more likely to drop below the OSI fracture threshold over 5 years in the two lowest activity quartiles (<7,000 and <6,900 steps/day and/or <18 and <17 min/day at >3 METs) than in the highest quartile (>9,100 and >8,800 steps/day and/or >30 and >25 min/day at >3 METs). Conclusion After adjustment for potential confounders, the calcaneal health of seniors is associated with both the daily step count and the duration of activity at an intensity >3 METs. The bone health is optimal in elderly people who take at least 7,000-8,000 steps/day and/or spend at least 15-20 min/day at an intensity >3 METs. [ABSTRACT FROM AUTHOR]

Objective: To determine appropriate management of the active individual with infectious mononucleosis (IM), including issues of diagnosis, the determination of splenomegaly, and other measures of disease status, the relationship of the disease to chronic fatigue syndrome (CFS), and the risks of exercise at various points in the disease process. Data Sources: An Ovid/MEDLINE search (January 1996-June 2015) was widely supplemented by "similar articles" found in Ovid/MEDLINE and PubMed, reference lists, and personal files. Main Results: Clinical diagnoses of IM are unreliable. Traditional laboratory indicators (lymphocytosis, abnormal lymphocytes, and a heterophile-positive slide test) can be supplemented by more sensitive and more specific but also more costly Epstein--Barr antigen determinations. Clinical estimates of splenomegaly are fallible. Laboratory determinations, commonly by 2D ultrasonography, must take account of methodology, the formulae used in calculations and the individual's body size. The SD of normal values matches the typical increase of size in IM, but repeat measurements can help to monitor regression of the disease. The main risks to the athlete are spontaneous splenic rupture (seen in 0.1%-0.5% of patients and signaled by acute abdominal pain) and progression to chronic fatigue, best avoided by 3 to 4 weeks of restricted activity followed by graded reconditioning. A full recovery of athletic performance is usual with 2 to 3 months of conservative management. Conclusions: Infectious mononucleosis is a common issue for young athletes. But given accurate diagnosis and the avoidance of splenic rupture and progression to CFS through a few weeks of restricted activity, long-term risks to the health of athletes are few. [ABSTRACT FROM AUTHOR]

Introduction: The effects of Ramadan observance and any associated dietary restriction upon oxidative stress are not well known. The topic has thus been examined in a brief systematic review of available literature concerning non-athletic but otherwise healthy subjects, patients with selected clinical conditions, and in athletes. Methods: Ovid/Medline and Google searches were supplemented by a perusal of reference lists in papers thus identified. Results: Ramadan observance and associated dietary restrictions are generally associated with a decrease of body mass in non-athletic adults, and in patients with conditions such as obesity, metabolic syndrome, diabetes mellitus and hypertension. During Ramadan, measures of oxidative stress (particularly malondialdehyde and F2 isoprostanes) are consistently decreased, antioxidant status (particularly levels of peroxidases, uric acid and reduced glutathione) are enhanced and inflammatory reactions (particularly c-reactive protein, IL-6 and TNF-a) are decreased in association with decreases in body mass. Perhaps because of lower initial body weights and greater dietary control during Ramadan, changes of oxidant status are more variable in athletes; in 3 of 7 studies, Ramadan observance had little effect on oxidant status, and in 2 reports there was some deterioration. In 3 of 4 studies where athletes underwent short-term dieting, there was also no improvement of antioxidant status. Conclusion: Ramadan observance and any associated dieting reduce oxidative stress in nonathletic individuals, apparently in association with decreases of body mass. In athletes, oxidant levels are generally unchanged during Ramadan, and if food intake is maintained they may even increase. More information is needed upon possible adverse health consequences, but chronic risks are probably small because any changes are limited to one month per year. [ABSTRACT FROM AUTHOR]

The Douglas bag technique is reviewed as one in a series of articles looking at historical insights into measurement of whole body metabolic rate. Consideration of all articles looking at Douglas bag technique and chemical gas analysis has here focused on the growing appreciation of errors in measuring expired volumes and gas composition, and subjective reactions to airflow resistance and dead space. Multiple small sources of error have been identified and appropriate remedies proposed over a century of use of the methodology. Changes in the bag lining have limited gas diffusion, laboratories conducting gas analyses have undergone validation, and WHO guidelines on airflow resistance have minimized reactive effects. One remaining difficulty is a contamination of expirate by dead space air, minimized by keeping the dead space <70 mL. Care must also be taken to ensure a steady state, and formal validation of the Douglas bag method still needs to be carried out. We may conclude that the Douglas bag method has helped to define key concepts in exercise physiology. Although now superceded in many applications, the errors in a meticulously completed measurement are sufficiently low to warrant retention of the Douglas bag as the gold standard when evaluating newer open-circuit methodology. [ABSTRACT FROM AUTHOR]

The human spleen shows a decrease in volume of around 40% early during vigorous exercise and in response to other stressful stimuli such as maximal apnoea and the breathing of hypoxic gas mixtures. Contraction seems an active response, mediated by alpha-adrenergic fibres in the splenic nerve. Given the relatively small size of the human spleen, the effect upon physical performance is likely to be small; the augmentation of total blood volume is <2%, and even taking account of other causes of haemoconcentration during vigorous exercise, the increase of haematocrit is <10%. However, one of two studies suggested that the haemoconcentration may be sufficient to cause errors in the traditional method for calculating exercise-induced changes of plasma volume. The spleen also contributes leucocytes and platelets to the general circulation as part of the “fight or flight” reaction to stressors. The mobilisation of leucocytes proceeds more slowly than that of the red cells; it depends not only upon an active contraction of the spleen, but also a modulation of leucocyte adhesion molecules. Splenectomy impairs exercise performance in horses, but human performance data are lacking; overall health effects seem minimal, and many patients live many years after removal of their spleens. [ABSTRACT FROM PUBLISHER]

The intermittent fasting of Ramadan could affect various aspects of body physiology and biochemistry important to athletic success. Much of the available information on this subject has been collected from sedentary subjects or low-level competitors, often without well matched controls. Other issues requiring clearer definition include the duration of fasting, the local environment, the timing of observations, and changes in training, diet and sleep patterns. Sleep may be shortened or made good with daytime naps. Circadian rhythms of temperature, metabolism, hormonal secretions and physical performance may be disrupted and incidental activities curtailed. Disturbances of psychomotor performance include daytime sleepiness, impaired vigilance and slower reactions. Food intake is limited to night-time meals. Sedentary individuals sometimes exploit Ramadan to reduce body fat stores. Well disciplined athletes usually maintain energy balance unless daily energy expenditures are very high. Protein intake must allow for gluconeogenesis, and provide quality protein ingested around training times. Blood sugar levels are likely to fall over a long and active day, even if morning glycogen reserves are maximized. Metabolism of fat should be encouraged, beginning prior to Ramadan; inclusion of fat in the pre-dawn meal also slows gastric emptying. Daytime fluid depletion is inevitable if athletes exercise in the heat, but the immediate deficit can usually be made good at night. Some studies show an initial fluid depletion, with recovery as Ramadan continues, possibly reflecting changes in urine and sweat production. Top athletes can maintain training throughout Ramadan, although coaches sometimes reduce demands through a pre-competitive tapering of effort. Late night or early morning training requires negotiation with players who are not observing Ramadan, and dietary adjustments to maintain optimal plasma amino acid levels when training. Performance of repeated anaerobic exercise is impaired, but aerobic power and muscular strength show little change during Ramadan. Ratings of fatigue are increased, and vigilance and reaction times are impaired, particularly during the afternoon. Medical issues during Ramadan are few. Athletes with diabetes mellitus should seek a medical exemption from fasting, and prescribed drug schedules should be carefully maintained. There is no major increase of injury rates, but competitors may have difficulty in producing urine for doping controls. Logical measures to minimize the effects of Ramadan include the optimization of mood state, maintenance of training, minimization of sleep loss, appropriate adjustments of diet, and the monitoring of competitors for chronic dehydration. Future research should concentrate on the changes observed in top athletes, particularly women, with data collected in the late afternoon after a known period of fasting in a well defined environment. It will be important to ensure that the lifestyle of those studied has been optimized. Implications of chronic dehydration for doping control also merit further investigation. Current data suggest that the impact of Ramadan upon athletic performance is small relative to the precision of test procedures, although it may be sufficient to cause a loss of medals. Negative effects vary widely with the type of sport, the season when fasting is observed, the local culture and the discipline exercised by the athlete. [ABSTRACT FROM AUTHOR]

Objectives To relate 5-year lean tissue loss to habitual physical activity of elderly adults. Design Longitudinal. Setting Community of Nakanojo. Participants Community-living Japanese aged 65 to 84 (200 men, 268 women). Measurements Daily 24-hour pedometer/accelerometer data, collected continuously for 5 years, were categorized into activity quartiles. Bioelectrical impedance measurements of lean body mass were taken annually. A sarcopenia threshold was defined arbitrarily as an appendicular lean mass/height2 of more than 1 standard deviation below the mean for healthy young Japanese. Results Subjects with greater habitual physical activity retained a greater lean mass over the 5 years of observation. Controlling for baseline lean mass and age, final lean mass was greater for the third activity quartile (men and women with respective mean counts of 7,800 and 7,700 steps per day or mean duration of exercise at >3 metabolic equivalents ( METs) of 20 and 17 minutes per day) than for the first and second quartiles. A multivariate-adjusted proportional hazards model predicted that, over the 5 years, men and women in the two lowest activity quartiles (<6,700 and <6,800 steps per day) were 2.3 (95% confidence interval ( CI) = 1.4-4.5) and 3.0 (95% CI = 1.9-3.4) times as likely, respectively, to be sarcopenic as those in the highest activity quartile (>9,000 and >8,400 steps per day). Likewise, men and women with less than 16 and less than 14 minutes per day, respectively, of activity of more than 3 METs were 3.0 (95% CI = 2.0-6.0) and 3.5 (95% CI = 2.1-6.3) times as likely to develop sarcopenia as those with more than 28 and more than 22 minutes per day. Conclusion After adjustment for potential confounders, the risk of developing sarcopenia was substantially lower in elderly people taking at least 7,000 to 8,000 steps per day or exercising for at least 15 to 20 minutes per day at an intensity greater than 3 METs. Clinicians should encourage seniors to get at least this volume of regular daily exercise. [ABSTRACT FROM AUTHOR]

Objective: To assess the influence of Ramadan fasting on maximal performance of moderately trained young men using various tests of muscle performance. Design: Comparison of Ramadan fasting (n = 10) versus control group (n = 10) over 3 test sessions, before Ramadan (B), at the end of the first week of Ramadan (R-l), and during the fourth week of Ramadan (R-4). Setting: At each 2-day test session, 4 tests were performed in the same order: measurement of vertical jump height (VJH) and a force- velocity test using the arms on day 1, and measurement of handgrip force (HGF), and a force-velocity test using the legs on day 2. Participants: Twenty trained men. Main Outcome Measures: Maximal power of the arms and of the legs (force-velocity testing), vertical jump performance, HGF, anthropometric data, dietary intake, hemoglobin, and hematocrit. Results: Two-way analyses of variance (group x time) showed Ramadan fasters with decreased maximal anaerobic power of the arms (Wmax-A) and legs (Wmax-L) at R-l, with a partial return of arm data to initial values at R-4. Vertical jump height and HGF remained unchanged throughout. Other changes in Ramadan observers were a decreased energy intake and a decrease of plasma volume at R-l. Conclusions: These results suggest that Ramadan observance initially had detrimental effects on Wmax-A, and Wmax-L, with a tendency to recovery by week 4 of Ramadan. Reductions of total energy intake and intramuscular glycogen may contribute to the reduced Wmax-A and Wmax-L during Ramadan fasting. [ABSTRACT FROM AUTHOR]

Abstract: We review sex differences in the relationship between habitual physical activity and health in the elderly, with particular reference to pedometer/accelerometer data from the Nakanojo Study. Maximal aerobic power, walking speed and habitual physical activity are 10–30% greater in men than in women. This reflects not only biological but also socio-cultural and environmental factors, with the latter becoming dominant as age advances. It implies a need for sex-specific thresholds of moderate activity. Overall health is associated with both the year-averaged daily step count (the best indicator in women) and the year-averaged daily duration of physical activity >3metabolic equivalents (METs) (the best indicator in men). In both sexes, the threshold ranges of step count and/or duration of activity >3METs associated with a reduced prevalence of health problems are: 4000–5000steps/day and/or 5–7.5min/day for impaired mental and psychosocial health, such as a depressed mood state and a poor health-related quality of life; 7000–8000steps/day and/or 15–20min/day for markers of aortic arteriosclerosis, osteoporosis, sarcopenia and poor physical fitness; and 8000–10,000steps/day and/or 20–30min/day for components of the metabolic syndrome, especially hypertension and hyperglycemia. Irrespective of sex, both the intensity and the total volume of physical activity are influenced by stressful life events, such as a partner''s death, and immediate meteorological factors, particularly precipitation and mean ambient temperature, underlining the need for long-term measurement of activity patterns. These findings have practical implications for those who engage in epidemiological studies and/or design health promotional programs for the elderly. [Copyright &y& Elsevier]

This review examines information on the effects of Ramadan observance upon the metabolism, training and performance of athletes, with particular reference to proteins and amino acids. Increased gluconeogenesis and/or a reduced intake of protein could lead to a decrease of lean tissue, with adverse effects on muscular performance, and the lack of immediate protein ingestion could compromise responses to strength training. Actual responses vary quite widely, depending on culture and the individual's level and type of athletic involvement. In elite competitors, there is typically an increased fractional ingestion of protein with a small reduction in overall energy intake, and this may lead to small reductions of body and lean tissue mass. There are often small decreases of performance, particularly in activities requiring vigorous and/or repetitive muscular contraction. More information is needed on responses in situations where protein intake is likely to be inadequate (adolescent growth, those maintaining vegetarian diets or from poor countries and disciplines with very high overall energy needs) and when vigorous muscle training is in progress. However, in most of the situations studied to date, Ramadan observance has had only limited adverse consequences for either training or competitive performance. [ABSTRACT FROM AUTHOR]

It has been suggested recently that financial links between manufacturers of sports drinks and professional Sports Science organisations in North America have suppressed information on the existence and ways of preventing an epidemic of exerciseassociated hyponatraemia (EAH). This article reviews evidence for the prevalence of both biochemical and clinical hyponatraemia. It concludes that a limited number of cases of EAH occur after ultra-long distance events, particularly when performed under cold and wet conditions, and that some eight deaths have been associated with EAH since 1985. However, this information has been widely reported, both in North America and in other parts of the world. Claims of an 'epidemic' seem unwarranted, and there is no solid evidence supporting the claim that information has been suppressed because of ties between sports scientists and sports drink manufacturers. [ABSTRACT FROM AUTHOR]

European and North American cardiologists have long debated the need for mandatory ECG screening of athletes in order to prevent sudden cardiac death. European investigators have recently adduced new evidence, which they believe supports the need for such screening. They note a decrease of sudden cardiac deaths among Italian athletes following the introduction of mandatory screening in that country, clearer definitions of resting ECG abnormalities in athletes, new and more encouraging calculations of cost/benefit ratios and direct comparisons of clinical examination alone against clinical examination plus ECG screening. Nevertheless, it seems that critical criteria for the success of any screening procedure (a substantial prevalence of the problem, coupled with an adequate test sensitivity and specificity) have yet to be satisfied. Very few athletes are liable to sudden cardiac death, only a few of those who are vulnerable will be identified by ECG screening, and even if all potential cases could be detected, restriction of their physical activity would be unlikely to have a major influence on their prognosis. At the same time, a requirement of mandatory testing would discourage engagement in physical activity, and would impose substantial direct costs on the community. Moreover, the large number of false positive test results could have important and undesirable consequences for both indirect medical costs and the overall health of competitors. ECG screening might become more effective if it could be focused on a smaller sub-group of vulnerable athletes, or if the problem of false positive tests could be addressed through an increase of test specificity. However, on the basis of current information, it would seem better to direct efforts in preventive medicine to more common causes of premature death in the young adult. [ABSTRACT FROM AUTHOR]

This article provides a detailed overview of both factors influencing habitual physical activity, and relationships between such activity and health in the elderly. Current cross-sectional data from the Nakanojo Study, which we have been carrying out since 2000, indicate substantial associations between the overall health of participants, and both the year-averaged daily step count and the year-averaged daily duration of effort undertaken at an intensity >3 metabolic equivalents (MET). In men, the extent of health is associated more closely with the daily duration of activity >3 MET than with the daily step count, whereas in women the association is closer for the step count than for the duration of activity >3 MET. In both sexes, the threshold amount of physical activity associated with better health is greater for physical than for mental benefits: >8000 vs >4000 steps/day and/or >20 vs >5 min/day at >3 MET, respectively. In other words, physical health is better in those spending at least 20 min/day in moderate walking (at a pace of around 1.4 m/s [5 km/h]) and a further >60 min of light activity per day. In contrast, better mental health is associated with much smaller amounts of deliberate physical activity. Both the intensity and the total volume of physical activity are influenced by meteorological factors, particularly precipitation and mean ambient temperature. Activity decreases exponentially to about 4000 steps/day as precipitation increases. Excluding the influence of rainfall, the daily step count peaks at a mean outdoor temperature of around 17°C; above and especially below such readings, physical activity decreases as a quadratic function of temperature. Seasonal changes in the microclimate should thus be considered when designing interventions intended to increase the habitual physical activity of older adults. Based on these findings, we are now developing preventive tactics that should contribute to health promotion, disease prevention and thus a reduction in medical expenses for elderly people. Geriatr Gerontol Int 2010; 10 (Suppl. 1): S236–S243. [ABSTRACT FROM AUTHOR]

This presentation explores the value of mechanical, electrical, and mathematical analogues in understanding and evaluating a variety of closely integrated transport processes in human biology. Particular attention is directed to a major interest of John Sutton: the factors limiting transport of oxygen from the atmosphere to the working muscles when exercising in a variety of hostile environments. In most circumstances, the limiting term in a closely linked chain of conductances seems to be in the blood stream, and its magnitude can be estimated by measurements of maximal oxygen intake. Despite recent criticisms of this index by those who have proposed a feed-forward control of maximal aerobic effort, conductance theory suggests that the main limitation of oxygen transport is normally maximal cardiac output. Therefore, careful laboratory determinations of maximal oxygen intake continue to provide a convenient integrating assessment of an individual's cardiorespiratory function, with many important applications in sports medicine and exercise science. [ABSTRACT FROM AUTHOR]

This review explores the implications of seasonal changes in physical activity for fitness and human health. Photosensitivity and nutrient shortages mediate animal hibernation via the hypothalamus and changes in leptin and ghrelin concentrations. Opportunities for hunting and crop cultivation determine seasonal activity in under-developed human societies, but in developed societies temperature and rainfall are dominant influences, usually over-riding innate rhythms. Both questionnaire data and objective measurements show that many groups from children to the elderly increase their physical activity from winter to spring or summer. Measurements of maximal oxygen intake and muscle strength commonly show parallel seasonal changes. However, potential effects upon body mass and body fat may be counteracted by changes of food intake; subsistence agriculturists sometimes maintain or increase physical activity at the expense of a decrease in body mass. In developed societies, body fat commonly increases during the winter, with parallel changes in blood lipids, blood pressure and blood coagulability; moreover, these changes are not always fully reversed the following summer. Most developed societies show increased all-cause and cardiac mortalities in the winter. Health consequences of seasonal variations in physical activity including an increased vulnerability to cardiac catastrophe and a year-by-year increase in total body fat seem most likely if the average level of physical activity for the year is low. Public health recommendations should underline the importance of maintaining physical activity during adverse environmental conditions by adapting clothing, modifying behaviour and exploiting any available air-conditioned indoor facilities. [ABSTRACT FROM AUTHOR]

Over the past 13 years, Noakes and his colleagues have argued repeatedly for the existence of a 'Central Governor', a specific brain centre that provides a feed-forward regulation of the intensity of vigorous effort in order to conserve homeostasis, protecting vital organs such as the brain, heart and skeletal muscle against damage from hyperthermia, ischaemia and other manifestations of catastrophic failure. This brief article reviews evidence concerning important corollaries of the hypothesis, examining the extent of evolutionary pressures for the development of such a mechanism, the effectiveness of protection against hyperthermia and ischaemia during exhausting exercise, the absence of peripheral factors limiting peak performance (particularly a plateauing of cardiac output and oxygen consumption) and proof that electromyographic activity is limiting exhausting effort. As yet, there is a lack of convincing experimental evidence to support these corollaries of the hypothesis; furthermore, some findings, such as the rather consistent demonstration of an oxygen consumption plateau in young adults, argue strongly against the limiting role of a 'Central Governor'. [ABSTRACT FROM AUTHOR]

In older adults, as in younger individuals, habitual moderate-intensity physical activity is associated with a reduced risk of various chronic health conditions, including certain types of cardiovascular and musculoskeletal disease and certain forms of cancer. However, the pattern of physical activity associated with such benefits remains unclear. One problem is that most investigators have examined patterns of physical activity using either subjective questionnaires or accelerometer or pedometer measurements limited to a single week, despite clear evidence of both the unreliability/invalidity of questionnaires and seasonal changes in activity patterns. Since 2000, we have thus conducted an interdisciplinary study examining the habitual physical activity and health of elderly people living in a mediumsized Japanese town (the Nakanojo Study). In about one-tenth of some 5000 available subjects aged ≥65 years, physical activity has already been assessed continuously for 24 h/day for >8 years using a specially adapted pedometer/ accelerometer. This device has a storage capacity of 36 days and can distinguish >10 intensities of physical activity (expressed in metabolic equivalents [METs]). Data have to date been summarized as daily step counts and daily durations of activity of <3 and >3 METs, averaged over a 1-year period. This article provides a detailed overview of both factors influencing habitual physical activity and relationships between such activity and health in an elderly population. To date, analyses have been cross-sectional in type. Substantial associations have been noted between the overall health of participants and both the daily duration of effort undertaken at an intensity of >3 METs and the daily step count. In men, the extent of health is associated more closely with the daily duration of activity of >3 METs than with the daily step count, whereas in women, the association is closer for the step count than for the duration of activity >3 METs. In both sexes, the threshold amount of physical activity associated with better health is greater for physical than for mental benefits: >8000 versus >4000 steps/day and/or >20 versus >5 min/day at an intensity >3 METs, respectively. In other words, better physical health is seen in those spending at least 20 min/day in moderate walking (at a pace of around 1.4m/s [5km/h]) and a further >60 min of light activity per day. In contrast, better mental health is associated with much smaller amounts of deliberate physical activity. The daily step count and the daily durations of activity of <3 and >3 METs are all influenced by meteorological factors, particularly precipitation and mean ambient temperature. Activity decreases exponentially to about 4000 steps/day as precipitation increases. Excluding the influence of rainfall, the daily step count peaks at a mean outdoor temperature of around 17°C; above and especially below such readings, physical activity decreases as a quadratic function of temperature. Seasonal changes in microclimate should thus be considered when designing interventions intended to increase the habitual physical activity of elderly people. The observed associations between physical activity and health outcomes point to a need for longitudinal analyses; these should examine potential causal interpretations of the current findings and elucidate possible additional mediating variables. [ABSTRACT FROM AUTHOR]

This brief review examines whether active commuting is an effective method of controlling the current obesity epidemic and enhancing the cardiovascular health of the population. Of the many potential methods of active commuting, walking and cycling are the usual choices. Children and adolescents prefer cycling, but for adults issues of safety, cycle storage and company dress codes make walking the preferred option, particularly in North American cities, where urban design and weather conditions often do not favour cycling. Active transportation is more frequent in some European countries with dedicated cycle and pedestrian paths, but in most developed societies, active transportation has declined in recent years.Attempts to increase walking behaviour in the sedentary population have had only limited success to date. A weekly gross energy expenditure of at least 4 MJ is recommended to reduce all-cause and cardiovascular mortality. This can be achieved by walking 1.9 km in 22 minutes twice per day, 5 days per week, or by cycling at 16 km/h for 11 minutes twice per day, 5 days per week. When engaged in level walking, the intensity of effort may be adequate for cardiovascular benefit in older adults, but in fit young workers, it is necessary to either increase the pace or choose a hilly route in order to induce cardio-respiratory benefit; in contrast, cycling is likely to provide an adequate cardiovascular stimulus even for young adults.Empirical data to date have yielded mixed results: a reduced all-cause and cardiovascular mortality has been observed more frequently in cyclists than in walkers, and more frequently in women and older men than in young active commuters. More information is needed concerning the typical weekly dose of activity provided by active commuting, and the impact of such commuting on overall attitudes towards physical activity. It is also necessary to find better methods of involving the sedentary population, through both counselling and changes in urban design. [ABSTRACT FROM AUTHOR]

This article documents current literature on the potential long-term effects of school physical education on various outcomes in adults. A first observation is the rarity of publications on this topic. Nevertheless, the available literature suggests that physical education should offer a variety of either lifelong physical activities or sports in order to reach children with differing interests. In some children, competitive sports may generate a lifelong interest in physical activity, but most children may be better socialized by lifelong physical activities. In order to expose children to such a wide choice of physical activities, more time should be allocated to physical education instruction. Substantial further research is needed to increase our understanding of the long-term impact of school physical education programmes. [ABSTRACT FROM AUTHOR]

Background: The purpose of this paper is to review relationships of academic performance and some of its determinants to participation in school-based physical activities, including physical education (PE), free school physical activity (PA) and school sports. Methods: Linkages between academic achievement and involvement in PE, school PA and sport programmes have been examined, based on a systematic review of currently available literature, including a comprehensive search of MEDLINE (1966 to 2007), PSYCHINFO (1974 to 2007), SCHOLAR.GOOGLE.COM, and ERIC databases. Results: Quasi-experimental data indicate that allocating up to an additional hour per day of curricular time to PA programmes does not affect the academic performance of primary school students negatively, even though the time allocated to other subjects usually shows a corresponding reduction. An additional curricular emphasis on PE may result in small absolute gains in grade point average (GPA), and such findings strongly suggest a relative increase in performance per unit of academic teaching time. Further, the overwhelmingly majority of such programmes have demonstrated an improvement in some measures of physical fitness (PF). Cross-sectional observations show a positive association between academic performance and PA, but PF does not seem to show such an association. PA has positive influences on concentration, memory and classroom behaviour. Data from quasi-experimental studies find support in mechanistic experiments on cognitive function, pointing to a positive relationship between PA and intellectual performance. Conclusion: Given competent providers, PA can be added to the school curriculum by taking time from other subjects without risk of hindering student academic achievement. On the other hand, adding time to "academic" or "curricular" subjects by taking time from physical education programmes does not enhance grades in these subjects and may be detrimental to health. [ABSTRACT FROM AUTHOR]

The purpose of this article is to provide an overview of objective assessments of the short- and long-term outcomes of elementary school physical education programs. Evaluations have used a variety of designs, including longitudinal and tracking studies as well as correlational analyses. The short-term effect of physical education on health and physical fitness is well documented. To date, most long-term data add little to the understanding of long-term effects, because researchers have rarely used an experimental design. Nevertheless, the available literature suggests that physical education should offer instruction in a variety of lifelong physical activities and sports, in order to reach children with differing interests. There is also an urgent need to perform quasi-experimental follow-up studies in various populations, assessing the extent to which benefits are modulated by changes in the type, duration, and frequency of the physical education program. [ABSTRACT FROM AUTHOR]

Although children and youth currently form the most active segments of the population in developed societies, there is a marked trend toward an increase in sedentary lifestyle among school-age children. The purpose of this review is to analyse the effects of school physical education (PE) programmes on: (i) the physical activity (PA) levels of participants as children and adults; and (ii) attitudes toward PE and PA in the same groups. Based on the literature analysed, it can be suggested that a sufficient quantity of a quality PE programme can contribute significantly to the overall amount of moderate-to-intense PA of the school-age child. Schools also have the potential to influence the habitual PA of children by encouraging increased participation in extracurricular sports activities, by favouring active commuting to school and by providing exercise equipment and supervision for youth in their neighbourhoods. Most young children have a very positive attitude towards PE. However, as they grow older, their perception of PE as a positive experience seems to become more ambiguous. From the few studies available, it seems likely that quality PE programmes help to maintain initial positive perceptions. Future research should address factors influencing the change of perceptions as a child matures. In addition to offering a quality PE programme, schools should ensure that the total weekly amount of PE is sufficient not only to maintain but also to enhance a child’s physical fitness. More research is needed to determine the ability of school PE programmes to influence PA behaviour in adult life and to evaluate strategies that will make optimal use of the curricular time allocated to PE. [ABSTRACT FROM AUTHOR]

Physical activity is an important part of the World Health Organization's integrated approach to the prevention and control of noncommunicable disease and the promotion of health, and, in particular, to the evolving World Health Organization Global Strategy on Diet and Physical Activity. To assist in these efforts, a joint World Health Organization/Centers for Disease Control and Prevention Consultation on Physical Activity Policy Development took place in Atlanta, Georgia, from September 29 through October 2, 2002. This article summarizes the context and outcomes of the consultation. It also includes elaboration of a Comprehensive Physical Activity Policy Framework developed as a product of the meeting. [ABSTRACT FROM AUTHOR]

Regression to the mean (RTM) can bias any investigation where the response to treatment is classified relative to initial values for a given variable without the use of an appropriate control group. The phenomenon and resulting errors of interpretation have been recognised by clinicians in a number of disciplines. The causes of RTM include both intra-individual variance and measurement error. The magnitude of RTM can be estimated quite simply, given a knowledge of intra- and inter-individual variance. RTM can be avoided by using a fully controlled experimental design. Difficulties can also be minimised by making duplicate measurements prior to the experimental manipulation, the first measurement serving for classification, and the second (with randomly distributed variance) allowing an assessment of the response to treatment. Less satisfactorily, surrogate measurements (for example, plasma volume for maximal oxygen intake [V-dotO[sub 2max]]) can assess the bias introduced by an initial non-random sorting of study participants. The impact of RTM on the design and interpretation of investigations has as yet received little consideration by exercise scientists and sports physicians. The response to training is often related to initial measurements of a dependent variable such as heart size, ST segmental depression, fitness or level of physical activity. In particular, analyses of this type have been adduced to support the belief that the response to aerobic training is inversely related to an individual’s V-dotO[sub 2max]. In fact, RTM may account for a major part of this apparent relationship. [ABSTRACT FROM AUTHOR]

The circulating blood normally contains no more than 1–2% of the body’s population of leucocytes. The numbers and phenotypes of circulating leucocyte subsets can change dramatically during and immediately following exercise. The surface expression of adhesion molecules makes an important contribution to such responses by changing patterns of cell trafficking. Alterations in the surface expression of adhesion molecules could reflect a shedding of molecules, selective apoptosis or differential trafficking of cells with a particular phenotype, effects from mechanical deformation of the cytoplasm, active biochemical processes involving cytokines, catecholamines, glucocorticoids or other hormones, or changes in the induction of adhesion molecules. The expression of adhesion molecules changes with maturation and activation of leucocytes. Typically, mature cells express lower densities of L-selectin (CD62L), the homing receptor for secondary lymphoid organs, and higher densities of LFA-1 (CD11a), the molecule associated with trafficking to non-lymphoid reservoir sites. The neutrophils and natural killer cells that are mobilised during exercise also express high levels of Mac-1 (CD11b), a marker associated with cellular activation. Possibly, exercise demarginates older cells that are awaiting destruction in the spleen. Plasma concentrations of catecholamines rise dramatically with exercise, and there is growing evidence that catecholamines, acting through a cyclic adenosine monophosphate second messenger system, play an important role in modifying the surface expression of adhesion molecules. Analogous changes can be induced by other forms of stress that release catecholamines or by catecholamine infusion, and responses are blocked by β[sub 2]-blocking agents. Catecholamines also modify adherence and expression of adhesion molecules in vitro. Cell trafficking is modified by genetic deficiencies in the expression of adhesion molecules, but leucocyte responses to exercise and catecholamines are generally unaffected by splenectomy. A number of clinical conditions including atherogenesis and metaplasia are marked by an altered expression of adhesion molecules. The effects of exercise on these molecules could thus have important health implications. [ABSTRACT FROM AUTHOR]

Results from this study show that in a sample of 332 German managers a Type A personality and an External locus of control are associated with greater perceived levels of stress (particularly in terms of inter-personal relationships), lower job satisfaction and a poorer physical and mental health than that of managers with a type B personality and an Internal locus of control. The magnitude of main effect size is substantially larger than the interaction terms (Type A×Locus of Control). There is no evidence to support a significant effect of a Type A×Locus of Control interaction on either of the health outcome measures (physical and psychological health), but there is some evidence of an interaction with work satisfaction outcomes (job satisfaction and organizational satisfaction). Those with an External locus showed significantly lower levels of work satisfaction, especially when this characteristic was combined with a Type A personality. It appears that negative health consequences may outweigh the superficial attractiveness of the type A personality in a managerial position, particularly when this trait is coupled with a more external locus of control. [Copyright &y& Elsevier]

Summary The application of epidemiological methods to exercise immunology is reviewed briefly, with particular reference to the possible influences of physical activity, exercise and training on susceptibility to upper respiratory infections. Available reports are arbitrarily rated in terms of limiting factors: the quality of the assessment of physical activity, the precision of diagnosis of upper respiratory infection and overall methodology. The pattern of physical activity has often been clearly established but, in part because of the problems associated with the competitive environment, assessments of infection and overall methodology have often been less than optimal. Although there is some evidence that susceptibility to infection is increased by either a single bout of very heavy activity or a period of heavy training, reports are far from unanimous, and in certain respects fail to meet the classical epidemiological criteria of a causal relationship. The issue is important to both the health and the success of the international competitor, and merits definitive investigation, using optimal methods to assess both activity patterns and infection. [ABSTRACT FROM AUTHOR]

The author looks at a study done in order to investigate the impact of one month fasting done by Muslims athletes in Ramadan, the ninth month of the Islamic calendar. Topics discussed include increase risk of greater decrease in blood glucose levels in Muslim players, increased risk of cognitive disturbances and the risk of injuries, and physiological and chronobiological changes in body during Ramadan intermittent fasting.

Aging is associated with a progressive decrement in various components of physical work capacity, including aerobic power and capacity, muscular strength and endurance, and the tolerance of thermal stress. A part of the functional loss can be countered by regular physical activity, control of body mass, and avoidance of cigarette smoking. Nevertheless, athletes who continue to train regularly still show a substantial aging of both physiological function and competitive performance, reflecting a deterioration of cardiac pump function, a decrease of muscle strength, and a progressive impairment of heat tolerance. These various changes are of concern to the occupational physician, because of the rising average age of the labor force. In theory, an over-taxing of the heart and skeletal muscles might be thought to lead to a decrease of productivity, manifestations of worker fatigue such as absenteeism, accidents, and industrial disputes, and an increased susceptibility to musculoskeletal injuries, heart attacks, and strokes. However, in practice, the productivity, health, and safety of the older worker pose relatively few problems. Reasons for this paradox are discussed, and it is stressed that in general there is no longer need to push workers to their physical limits because of automation-related changes in methods of production. [ABSTRACT FROM AUTHOR]

Recent literature on the biology and medicine of soccer (primarily since 1990) has been accumulated by a combination of computer searching of relevant databases and review of the author's extensive files. From a total of 9681 papers, 540 were selected for closer scrutiny and 370 are discussed in the present review. These articles cover patterns of play and the resulting energy demands, the nutritional requirements of soccer, the anthropometric, physiological, biochemical and immunological characteristics of successful players, the influence of environmental stressors (heat, cold, hypoxia and time zone shifts), special features of female and junior competitors, selected issues in training, and the incidence and prevention of injuries. The information presented has important implications for the safety and success of soccer players; the challenge is now to ensure that this information is understood and acted upon by coaches and individual team members. [ABSTRACT FROM AUTHOR]

The biology and medicine of rowing are briefly reviewed. Effort in a 2000-m race is about 70% aerobic. Because the boat (and in some instances a cox) must be propelled, successful competitors are very tall, with a large lean mass and aerobic power. Large hearts may lead to erroneous diagnoses of a cardiomyopathy. Large respiratory minute volumes must be developed by chest muscles that are also involved in rowing. The vital capacity is typically large, and breathing becomes entrained. Expiration cannot be slowed relative to inspiration (as normally occurs at high rates of ventilation) and the limiting flow velocity may be reached, with the potential for airway collapse. Performance is strongly related to the power output at the 'anaerobic threshold', and lactate measures provide a guide to an appropriate intensity of endurance training. Peak blood lactate levels are higher in males (commonly 11-19 mmol . l[sup -1] and occasionally as high as 25 mmol . l[sup -1]) than in females (9-11 mmol . l[sup -1]), probably because males have a greater muscle mass in relation to blood volume. The skeletal muscles are predominantly slow twitch in type, developing an unusual force and power at low contraction velocities. Many rowers have a suboptimal diet, eating excessive amounts of fat. Lightweight rowers also have problems of weight cycling. Aerobic power and muscle endurance often change by 10% over the season, but such fluctuations can be largely avoided by a well-designed winter training programme. Injuries include back and knee problems, tenosynovitis of the wrist and, since the introduction of large blades, fractures of the costae. [ABSTRACT FROM AUTHOR]

Discusses the interrelationship among physical activity, health and well-being at different life stages. Childhood; Adolescence; Adult life; Old age.

Dietary intakes were compared in two groups of patients with anorexia nervosa, those who had earlier been "heavy" (n=27, peak body mass= 65.0 ± 7.6 kg) and those who had always been "light" (n=25, peak body mass = 51.5 ± 7.3 kg). Both groups were initially given a food intake of 7.5 MJ per day, and this was increases as needed to yield a controlled 1-2 kg per week increase of body mass. Body mass was restored most rapidly in the patients who reached the lowest weights, whether the classification was based upon the lowest body mass observed during the illness (gain in weeks 0-7, p < .002) or the body mass on admission to hospital (gain in weeks 0-14, p < .02, weeks 7-14, p < .01). Classifying patients in terms of their peak premorbid mass, the light group consumed food energy at a faster rate than the heavy group over the first 7 weeks of hospital treatment (p < .008), but nevertheless they did not gain more weight. Food intake reached a plateau in both groups between weeks 7 and 14 of treatment, although the light group was still consuming more energy than the heavy subjects (p < .005). Prospective observations on two light and two heavy patients confirmed both the time course of weight gain and the greater energy needed for a given increase of body mass in light patients. It is suggested that during the early stages of recovery from anorexia nervosa, energy utilization is more efficient in the heavier patients. However, it seems more difficult to sustain a high food intake in such patients, possibly because they fear a return to obesity. [ABSTRACT FROM AUTHOR]

Presents the results of the Trois Rivieres experiment involving primary school children in the Saint Maurice region of Quebec which determined the effects of physical activity on intellectual development and academic performance. Theoretical considerations regarding cognitive and psychomotor performance; Teacher-related effects; Student-related effects; Policy implications.

Examines the use of an extracurricular physical activity program to enhance social skills among children with learning disabilities. Social skills training as a form of therapy for children with learning disabilities; Children's need for individual instruction in social skills; Differentiation of learning disabilities in individuals.

The author reflects on the European Society of Cardiology and American Heart Association (AHA)'s bid for the cardiovascular screening of athletes to prevent sudden exercise-induced death. It mentions an argument on the efficacy of electrocardiogram (ECG) screening, as compared to conventional history and physical examination. Furthermore, the author states that the practice in North America is more advisable than in European countries.