We systematically investigate whether the time-of-day influences physiological responses to exercise. PubMed, CENTRAL and Web of Science were searched until June 2023. Studies must have been clinical trials with human participants classed as healthy, 'overweight' or obese, with type 2 diabetes mellitus (T2DM) or with treated/pre-hypertension. Single exercise bouts (acute: T-1; T-2) and training programmes (chronic: T-3) performed in the morning (AmEx) and in the afternoon/evening (PmEx) were included. Data were extracted for V.O2max/peak, vascular glucose and blood pressure (BP). 625 participants were included. PmEx resulted in significantly lower blood pressure vs. AmEx in the following analyses: mean arterial blood pressure (MABP) at T-1 (Standard Mean Differences (SMD) = 0.50; 95% CI : 0.12, 0.88) and T-2 (SMD = 0.35; 95% CI : 0.06, 0.65); systolic BP at T-2 (SMD = 0.32; 95% CI : 0.05, 0.58; n = 9 studies) and T-3 (SMD = 0.32; 95% CI: 0.02, 0.62) and diastolic BP at T-2 (SMD = 0.34; 95% CI : 0.05, 0.63). Similarly, blood glucose levels were lower for PmEx in participants with T2DM and/or overweight and obesity at T-3 (SMD = 0.45; 95% CI: 0.06, 0.83). PmEx elicits significant reductions in multiple analyses vs. AmEx.

Concussion in football is a serious injury, requiring prompt recognition and removal from play. In football, also known as soccer, referees play a key role in concussion management, alongside players, coaches, medical staff and governing bodies, by observing a head impact and stopping play to allow medical personnel to enter the field of play. However, their knowledge and attitudes surrounding concussion remain underexplored. This cross-sectional study assessed concussion knowledge and attitudes among football referees in Northern Ireland using the Rosenbaum Concussion Knowledge and Attitudes Survey (RoCKAS), together with items on concussion education, personal experience, and perceived role. Fifty-four referees affiliated with the Irish Football Association completed an online survey (a response rate of approximately 7%; 53 male, 1 female; mean age 44 years). Referees demonstrated good overall knowledge (Concussion Knowledge Index 19.6 ± 2.0 of 25) and safe attitudes (Concussion Attitude Index 12.9 ± 1.9 of 15), despite only 7.4% (n = 4) having received any formal concussion training. Overall, results support the need to implement concussion education within referee development pathways to enhance player safety and concussion management practices.

Abstract Background There is a high prevalence of injury in adolescent sports including time loss and non-time loss related injury. This study aims to investigate the risk factors associated with sports injury severity from time loss to non-time loss injuries in adolescent sports. Methods This was a prospective cohort study. At baseline, sports participation, demographic factors and dynamic balance using an inertial sensor instrumented Quantified Y-balance Test (QYBT) were captured. Participants were followed bi-weekly for one school year to record athletic exposures and injury status using a modified Oslo Sports Trauma Research Centre Overuse injury questionnaire. Multilevel ordinal regression models analysed the association between injury severity and risk factors of interest including age, gender, bodyweight, body mass index, somatic maturity, athletic exposures and QYBT derived dynamic balance metrics (Normalized reach distance, jerk magnitude root mean squared, gyroscopic magnitude root mean squared and gyroscopic sample entropy). Results Of 140 adolescents (56% female) that took part, 117 were included in analysis. 63% reported at least one injury. Higher gyroscopic values in the posteromedial reach direction had lower odds of more severe injury (Odds Ratio: 0.89; 95% Confidence Interval: 0.81–0.98). Higher weekly athletic exposures were associated with higher odds of sustaining a more severe injury (Odds Ratio: 1.11; 95% Confidence Interval: 1.04–1.18). Conclusions Adolescents in a mixed sport population who have higher athletic exposures and poorer dynamic balance performance as assessed using the QYBT are at higher risk of more severe injury. Dynamic balance and athletic exposures represent trackable and modifiable factors that are associated with injury in adolescent sports.

Despite the developmental benefits of sport in adolescence, injury is common and can have a profound impact beyond just physical symptoms.This qualitative study aims to explore the lived experiences of adolescent athletes with sports- related injury in Ireland.This was a qualitative study using one-on-one semi-structured interviews and a phenomenology method. Twenty-one secondary school students from across the Island of Ireland aged 15–18 years who had experienced a sports-related injury within the last 2 years agreed to take part. Reflexive thematic analysis was used to analyse the collected data.Seventeen adolescents (eight female, mean age 16.2 (range 15–18) years) from five different sports were included for analysis. Predominantly negative experiences were described with four overarching themes identified through thematic analysis: playing through pain and injury, the social influence on playing through pain and injury behaviour, the psychological impact of sports injury and player confidence and its role in returning to sport.In conclusion, a culture of playing through pain and even injury is widely accepted in adolescent sports and is influenced by the social circles that surround these young athletes. The impact of sports injury goes beyond just the physical, with these athletes experiencing devastation and a loss of identity due to their absence from sport. Sports coaches can help reduce this negative impact by keeping injured players involved in the team/sport as much as possible. Conversely, sports injury also provided opportunity for personal growth in some cases, improving mental resilience and self-reliance.

ABSTRACTObjectivesContact with the head should be avoided during a rugby league tackle, given the inherent risks of head injuries. This study aimed to characterise a sample of tackles, retrospectively identified as resulting in a potential head injury by the Rugby Football League (RFL) match review panel.DesignRetrospective video analysis study.Methods746 tackles, identified by the RFL match review panel from the men's 2018 and 2019 Super League seasons, were analysed. Video clips were coded using an adapted analysis framework, characterising tackle stage, head contact, affected player, offending player/surface, offending body part/surface and tackle sanctioning. Data were reported as frequencies and percentages.ResultsThe majority of tackles resulting in a potential head injury occurred in the initial tackle contact stage (n = 590, 79.2%). The ball‐carrier was most frequently affected (n = 372, 49.9%) compared to initial tacklers (n = 213, 28.6%). The initial tackler was the most frequently impacting player (n = 268, 36.0%), with the majority of potential head injuries occurring from direct head contact by the arm (n = 230, 34.1%), shoulder (n = 170, 25.2%) and head/neck (n = 145, 21.5%) of the impacting player. Head contact was present in 90.6% (n = 675) of the tackles resulting in a potential head injury. Of the sample of tackles, 16.1% (n = 109) of direct head contact events received a sanction from on‐field match officials.ConclusionThe initial tackle contact between the ball‐carrier and initial tackler remains the area of focus for research into potential head injuries in elite‐level men's rugby league, to improve awareness and understanding of the mechanisms of injury.

OBJECTIVES:To determine accuracy of clinical examination in grading ankle ligament sprain severity, using ultrasound (US) imaging as the reference standard. DESIGN:Cross-sectional study. SETTING:Rehabilitation centre. PARTICIPANTS:Sixty-eight athletes with an acute lateral ankle sprain (LAS) (<15 days). MAIN OUTCOME MEASURES:We performed clinical examinations to grade injury severity: anterior drawer test (ADT), talar tilt test (TTT), palpation and bruising, and patient's perception. Ultrasound imaging (US) was subsequently undertaken as reference standard. We also evaluated combinations of stress tests with palpation and bruising using a believe the negative (BTN) or positive (BTP) approach. We used Cohen's Kappa and Weighted Kappa to analyse agreement between clinical and US grading. RESULTS:ADT and TTT demonstrated moderate agreement with US for grading ATFL (ĸ = 0.547) and CFL injuries (ĸ = 0.507), and Palpation & bruising to grade CFL injury (ĸ = 0.529). Clustering TTT with palpation & bruising increased agreement with BTN approach (ĸ = 0.609). Patients' perception showed slight agreement (ĸ = 0.037) with US. CONCLUSION:Manual stress tests demonstrate moderate utility for grading grade ATFL and CFL injury severity; combining these tests with palpation (BTN approach) yields higher agreement. US can support more precise grading and should be implemented to enhance ligament injury severity grading after LAS.

Underpowered study designs undermine the reliability of experimental research, with growing concerns regarding randomised controlled trials (RCTs) informing musculoskeletal injury management. We assessed the statistical power and sample size calculations of such RCTs. Electronic searches (MEDLINE and PEDro searched up to March 2024) identified meta-analyses of RCTs comparing conservative interventions for musculoskeletal injury, without restrictions on demographics, injury type, or outcome. Statistical power was estimated using two approaches: (1) meta-analytic—the RCT’s power to detect the summary effect of the meta-analysis it contributed to, and (2) conventional—the RCT’s power to detect Cohen’s small (d = 0.2), medium (d = 0.5), and large (d = 0.8) effect sizes. The RCTs’ manuscripts and registry entries were screened for sample size planning details. The search identified 4737 articles, with 41 eligible meta-analyses of 266 RCTs. The median power was 42

Objectives:To describe training loads and injury incidences, and explore their relationship in senior schoolboy rugby players in Leinster, Ireland. Methods:Prospective cohort study conducted during the 2019-2020 season. Methods aligned with consensus statements for rugby injury surveillance research. Injuries were coded using the Orchard Sports Injury Classification System (OSICS) version 10.1 and recorded using the World Rugby Injury Surveillance System. Training load measures (session type, duration and rate of perceived exertion) were recorded by the players using The Sports Office smartphone application. Results:In total, 463 participants (mean age 17, (SD=0.9 years)) in 16 schools provided data over 20 weeks. Injury incidence per 1000 player hours was 19.9 (95% CI: 15.2 to 25.6) match injuries and 0.7 (95% CI: 0.4 to 1.0) training injuries. Median injury severity was 22 days (95% CI: 17 to 28) lost for match injuries and 14 days (95% CI: 5 to 41) lost for training injuries. Frequent injury sites included shoulder (n=23, 27%), head (n=22, 26%), wrist/hand (n=9, 11%), ankle (n=8, 10%) and knee (n=5, 6%). Tackle accounted for 49% of injuries. Players' recording of individual training load showed 11.5% compliance. Exposure was calculated as 31 141 training hours and 3063 match hours. Training sessions included conditioning weights (31%), rugby skills: non-contact (28%) and semicontact (24%), with variation in proportion of sessions across schools. Conclusion:Match activity and tackle events accounted for most injuries. Training exposure and type varied widely across schools. Low compliance in recorded individual training load limited analysis of association with injury risk, highlighting the challenge in identifying injury risk factors in an adolescent cohort.

Background: To investigate how physiotherapists approach lateral ankle sprain (LAS) rehabilitation and their rationale for exercise progression. We also sought to determine typical exercise dosage prescribed and the extent to which they rely on objective outcomes for guiding rehabilitation progression and return-to-sports decisions. Methods: We distributed an online survey using Qualtrics. The survey comprised a combination of 23 open and 8 closed questions to capture data on: participant demographics and clinical experience, typical caseload, LAS rehabilitation dosage, with clinical vignettes used to determine the time taken to reach key rehabilitation milestones, use of objective markers to inform rehabilitation progress, and progression to each milestone. Data were analyzed descriptively; open questions were inventoried and categorized. Proportions were then calculated per category. Results: Ninety-six physiotherapists from Belgium, the Netherlands, and the United Kingdom responded to the survey, of which 23 completed all sections. On average, less than half (46%) of the responding therapists use objective measurements to guide rehabilitation progress. The estimated time to reach key clinical milestones is equivocal among participating physiotherapists. Most physiotherapists use pain and ankle impairments (eg, range of motion and muscle strength) to guide rehabilitation progress. Conclusion: This study indicates that progress in LAS rehabilitation is determined subjectively and that not the entire spectrum of impairments is assessed. Physiotherapists should implement more objective measures throughout LAS rehabilitation.

Debate over the benefits and harms of icing acute muscle injuries remains unresolved.Some contend that ice is ineffec-tive or even harmful,while others promote cryotherapy as a universal remedy.Centrists,often academics,call for more high-quality randomized controlled trials(RCTs)to resolve the issue.

Sports-related concussions (SRCs) are a major health issue in athletes of varying ages, ability levels, and sports. Concerns over the short- and long-term consequences of SRCs have incentivized a wealth of products and policies aimed at reducing SRC risk. Research suggesting the effectiveness of such interventions at reducing SRCs has facilitated their adoption by sports organizations and, in some cases, product commercialization. However, the body of SRC mitigation research is almost entirely devoid of placebo or sham groups, which raises important questions about the true clinical effectiveness of these interventions. This Current Opinion explores the plausibility of placebo effects within the scope of SRC prevention, describes why the lack of placebo/sham groups in the current body of literature is problematic, and provides recommendations for including placebo/sham groups in future SRC research.

Over the two last decades, whole-body cryotherapy/cryostimulation (WBC) has emerged as an exciting non-pharmacological treatment influencing inflammatory events at a cellular and physiological level, which can result in improved sleep quality, faster neuromuscular recovery after high-intensity exercise, and chronic pain relief for patients suffering different types of diseases (fibromyalgia, rheumatism, arthritis). Some evidence even suggests that WBC has benefits on mental health (depression, anxiety disorders) and cognitive functions in both adults and older adults, due to increased circulating BDNF levels. Recently, some safety concerns have been expressed by influential public health authorities (e.g., FDA, INSERM) based on reports from patients who developed adverse events upon or following WBC treatment. However, part of the data used to support these claims involved individuals whose entire body (except head) was exposed to extreme cold vaporized liquid nitrogen while standing in a narrow bathtub. Such a procedure is known as partial-body cryotherapy (PBC), and is often erroneously mistaken to be whole-body cryotherapy. Although having similarities in terms of naming and pursued aims, these two approaches are fundamentally different. The present article reviews the available literature on the main safety concerns associated with the use of true whole-body cryotherapy. English- and French-language reports of empirical studies including case reports, case series, and randomized controlled trials (RCTs) were identified through searches of PubMed, Scopus, Cochrane, and Web of Science electronic databases. Five case reports and two RCTs were included for a total of 16 documented adverse events (AEs). A critical in-depth evaluation of these AEs (type, severity, context of onset, participant’s medical background, follow-up) is proposed and used to illustrate that WBC-related safety risks are within acceptable limits and can be proactively prevented by adhering to existing recommendations, contraindications, and commonsense guidelines.

Whilst cold therapies such as cold-water immersion are regularly used in practice, the practical application does not always align with best practices. In this commentary, we highlight the key components of the British Association of Sport and Exercise Sciences (BASES) Expert Statement on the use of cooling therapies for post-exercise recovery and provide additional discussion on the empirical evidence and rationale that informed our perspective. We developed a series of specific questions to ensure that cold therapy recovery protocols are context-specific and tailored to the needs of the individual athletes. These questions, which cover the WHEN, WHAT, and HOW of cold therapy, were central to the development of the Expert Statement. This was presented as a decision tree to ensure that key messages could be concisely disseminated across a range of sporting environments and populations (e.g., gyms, locker rooms, and treatment rooms), supporting and informing decision-making for those wanting to use cold therapy to assist their recovery in line with previously published peer-reviewed work. Discussion points included the suitability of cooling therapies in some contexts, how athletes’ choice of cooling mode should be largely driven by practicalities (e.g., budget and availability), and, lastly, future research directions.

Objectives To provide an overview of the outcome measures currently used after sports-related concussion (SRC) in adolescents, categorising by the constructs they assess, follow-up duration and their feasibility of use.Design Scoping review.Data sources We searched three electronic databases (MEDLINE, EMBASE and CINAHL). We also undertook citation tracking of the included articles and searched for ongoing or unpublished trials using ClinicalTrials.gov and Theses Global.Eligibility criteria Studies tracking concussion recovery in adolescent athletes.Results 15 782 records were identified. After initial title and abstract screening, we retrieved 87 studies for full-text screening, with 75 studies fulfilling the eligibility criteria and included in the review, comprising 13 107 participants (9480 male, 3615 female and 12 unreported), ranging in age from 5 to 19 years. 46 different outcome measures were used, with Post-Concussion Symptom Scale (n=42) and Immediate Post-Concussion Assessment and Cognitive Testing (n=21) the most common. Most outcome measures quantified aspects of sensorimotor function including balance, oculomotor function and cognition. Follow-up duration ranged from 7 days to 1 year. 60% of studies ceased follow-up assessments within 6 weeks post-SRC.Conclusions Adolescent SRC literature uses a wide range of outcome measures. Most research quantifies cognitive/fatigue domains in the acute/subacute stages post-SRC, using male participants. Other key domains such as anxiety/mood, migraine and key modifiers (cervical and sleep disturbance) are less well represented in the literature. Many of the outcome measures used in current research are associated with high cost and require highly qualified examiners, creating barriers to their implementation in some adolescent sporting environments.Study registration https://doi.org/10.17605/OSF.IO/N937E

Purpose: As part of the current process to support GPs with their ever-increasing workload, First Contact Physiotherapy Practitioners (FCPPs) are being employed into primary care based multidisciplinary teams. 'Empathy' has been identified as a key factor in defining the quality of care provision and has been shown to impact patient enablement and adherence to treatment regimens, patient and clinician satisfaction and both pain and anxiety levels. There is, however, no published research which analyses patient perceptions of empathy in clinical encounters with FCPPs.

Introduction Changes to the pupillary light reflex (PLR) have been demonstrated in traumatic brain injury and in adolescents with a history of concussion. Assessment of changes to the PLR following concussion has been proposed as a potential biomarker. Objectives Assessment of the reliability of PLR measurements in a cohort of elite female athletes. Determination of the discriminant validity of PLR metrics in athletes with and without a history of concussion. Design, Setting and Participants A cross-sectional cohort study of 33 international female field hockey athletes. Exclusion criteria: any neurological or ocular disease, eye trauma, exercise within one hour of testing and athletes taking medication that would affect PLR e.g., antidepressants. Outcome Measures Three valid pupilometer readings of each eye were obtained using the NeurOptics PLR-3000. Eight PLR metrics were measured; maximum and minimum pupil diameter, percentage of pupil constriction, constriction latency (CL), average constriction velocity (ACV), peak constriction velocity (PCV), average dilatation velocity (ADV) and T75%. Results NeurOptics PLR-3000 demonstrated good-to-excellent reliability (0.78–0.99 ICC) for all PLR metrics. No statistically significant differences (p>0.05) were demonstrated between those with and without a history of concussion. Trends towards slower PLR metrics (CL, ACV, PCV and ADV) were noted in athletes with a recent concussion (< three months) and athletes with three or more concussions. Conclusion In this limited pilot study, PLRs have promise as a rapid, reproducible, and objective physiological biomarker for concussion. Further validation is required in larger cohorts alongside investigation of the responsiveness of PLR metrics during acute concussion.

Abstract Purpose Adolescent athletes who sustain a sports-related concussion may experience a prolonged recovery period. Evidence suggests female athletes and those with a history of previous concussion may have an extended recovery period, spanning multiple weeks to months. The purpose of this study was to track recovery from a concussion across patient-reported measures and determine the time taken to return to pre-injury levels in adolescent rugby union players. Study design A longitudinal study was utilised across a single rugby union playing season (2022-23). Ethical approval was granted from Ulster University Research Ethics Committee Methods Male and female rugby union players were recruited from nine school and club rugby teams across Northern Ireland. To be eligible, participants had to be 16-18years of age, injury free and currently playing at First XV level. Participants completed demographic and established questionnaires including Post-Concussion Symptom Scale (PCSS), Concussion Clinical Profiling (CP), Paediatric Fear Avoidance Behaviour after Traumatic Brain Injury (PFAB-TBI), General Anxiety Disorder (GAD) and Patient Health Questionnaire (PHQ). Those who sustained a concussion were re-assessed at 3, 7, 14, 23, 90 and 180days post-event. Recovery was defined as questionnaire score at pre-injury level. The primary outcome measure was Post-Concussion Symptom Scale. Results Of the 149 participants (113M (76%); 36F (24%)), 11 (7%) sustained a concussion during the season (9M: 2F), of which four had a previous history of concussion (2M: 2F). PCSS and PFAB-TBI took the longest time to return to baseline scores. Statistically significant differences in survival distribution (Chi-square 9.27 (df = 4) p < 0.05) across self-reported outcomes; pairwise comparisons show the largest differences in survival distribution were seen between PCSS and GAD (p = 0.02) and PCSS and PHQ (p < 0.04). Conclusions Adolescent male and female rugby union players experienced prolonged post-concussive symptoms based on self-reported measures. Further research on male and female adolescent athletes is needed to track recovery across various clinical measures. Funding This study was funded by the Department for the Economy (DfE) as part of a sponsorship of postgraduate students

Background Concussion diagnosis is based on subjective assessment of several nonspecific clinical signs and symptoms with no objective test to aid in diagnosis. The pupillary system, in particular the pupil light reflexes (PLR) has attracted plausible consideration in this area, given its complex neural circuitry and autonomic function. Aim To assess the reliability and validity of using the NeurOptics PLR-3000 pupilometer to measure PLR, and to determine normative data for female athletes. Methods A cross sectional cohort study of 33 senior elite female field hockey athletes (aged 19–34 years) were recruited. Three valid pupillometry readings were acquired, per eye. Measurements of nine PLR metrics were obtained. Reliability was determined using intraclass coefficients, standard error of measurement (SEM), and minimum detectable change (MDC). Between group differences (concussion history vs. controls) were analysed using non-parametric tests. Results NeurOptics PLR-3000 showed good to excellent reliability for eight PLR metrics derived from the pupilometer [latency, average constriction velocity (ACV), peak constriction velocity (PCV), average dilation velocity (ADV), T75% max . pupil diameter, min. pupil diameter and percent constriction]. There was no statistical difference between any of the PLR metrics in athletes who had a history of concussion and those that had no history of concussion. The two athletes with a recent history of concussion (< 3 months) showed trends towards slowed latency, ACV, PCV and ADV when compared to controls. Conclusion This research does not support previous research that the PLR-3000 is an accurate instrument for distinguishing between those with and without a history of concussion. However, the ICC values for intratester reliability were good to excellent for most PLR metrics, with data comparing favourably to normative values previously reported from other populations. Some PLR metrics may distinguish between distinct group of female athletes (recent history of concussion), but this is a small sample size and exploratory in nature. Larger studies are required to confirm its validity and responsiveness.