Background: Infrared thermography (IRT) offers a non-invasive means to monitor skin temperature and physiological changes during rehabilitation. However, variability in image segmentation methods limits its broader clinical use. This study assessed the inter-rater reliability of a manual thermal image segmenatation protocol using FLIR Thermal Studio Pro™ and presents a longitudinal single-case feasibility illustration evaluating the agreement between this manual method and automatic segmentation using ThermoHuman®. Methods: Two regions of interest (ROI) were analyzed throughout the study: the frontal knee and vastus medialis oblique (VMO). For the inter-rater reliability analysis, thermal images from 20 professional athletes were used. For the agreement analysis, 50 lower extremity thermal images were captured from a single athlete recovering from a meniscal repair over a four-month rehabilitation period. Intraclass correlation coefficients (ICC (2,1)) were used to assess agreement and reliability. Results: Inter-rater reliability was excellent for all frontal knee measurements (ICC (2,1) = 0.991, 0.995, and 0.964 for maximum, average, and minimum temperature, respectively) and for VMO maximum and average temperature (ICC (2,1) = 0.967 and 0.981, respectively), with VMO minimum temperature as the exception demonstrating good reliability (ICC (2,1) = 0.779). Excellent agreement was found between methods for all frontal knee (ICC (2,1) = 0.967, 0.949, and 0.985) and VMO measurements (ICC (2,1) = 0.971, 0.973, and 0.980) for maximum, average, and minimum temperature, respectively. Conclusion: Manual segmentation using FLIR Thermal Studio Pro™ provides highly reliable results across multiple subjects, supporting its use as a practical and consistent clinical tool. Furthermore, our single-case feasibility illustration suggests it provides comparable results to automatic segmentation using ThermoHuman®, supporting its potential feasibility for accessible rehabilitation monitoring in injured athletes. Further multi-subject research is warranted to confirm the broader applicability of the agreement findings.

Background: Top surgery is an important procedure for Two Spirit, trans, gender diverse, and non-binary (2S/TGDNB) individuals however, standardized aftercare recommendations and consistent timelines for rehabilitation are lacking. The purpose of our study was to measure patient-reported upper limb function, socio-environmental engagement, pain interference, and pain severity in individuals receiving top surgery, over an 11-week rehabilitation program. Methods: Forty-two 2S/TGDNB individuals participated. Individualized rehabilitative aftercare started 10-days postoperatively, and included one treatment per week, for 11 weeks. Upper limb function was measured using the Disabilities of the Arm, Shoulder, and Hand scale. Socio-environmental engagement was assessed using a subsection of the Body Dysmorphic Disorder Symptom Scale while pain interference and pain severity were evaluated with the Brief Pain Inventory. Questionnaires were completed prior to surgery, then again at weeks 1, 5, and 11 postoperatively. Separate repeated-measures analyses of variance were used to identify differences in all measures across the 4 time points. Results: During an 11-week rehabilitation program, our participants experienced a significant statistical and clinical improvement in upper limb function (p < 0.001; eta 2= 0.878). Participants self-reported avoiding approximately 3 less socio-environmental experiences which represents a clinically significant improvement in socio-environmental engagement (p < 0.001; eta 2= 0.331). Lastly, pain interference (p < 0.001; eta 2 = 0.6) and pain severity (p < 0.001; eta 2= 0.372) did not negatively impact the rehabilitation. Conclusion: Our findings demonstrate that standard postoperative rehabilitation benefited a cohort following top surgery. The timeline for rehabilitative care used in this study can be applied by qualified care providers to support individuals following top surgery.

Abstract Background Muscular dysfunction of the lumbar-pelvic-hip complex is a hallmark of chronic low back pain (cLBP). This dysfunction is partly driven by muscle morphometry and composition, highlighting their importance in cLBP. Exercise-based interventions are commonly used in cLBP management; however, the extent to which different therapeutic approaches influence gluteal muscle health remains unclear. Aquatic therapy may offer a distinct therapeutic environment by reducing spinal loading while facilitating progressive muscle activation. Objectives This study aimed to (1) investigate the effects of aquatic therapy (AT) versus standard care (SC) on gluteal muscle size, intramuscular fat (IMF) and strength in patients with cLBP and (2) investigate whether positive changes in gluteal muscle health (i.e., size, composition, strength) are associated with concomitant improvements in patient-oriented outcomes. Methods This randomized controlled trial included 34 participants with moderate-to-severe cLBP. The participants were randomized to either AT (n = 18) or SC (n = 16). Both groups completed a 10-week supervised intervention program consisting of 2 sessions per week. The baseline and postintervention assessments included pelvic magnetic resonance imaging, gluteal strength testing, and patient-reported questionnaires. Changes in muscle-related and patient-oriented outcomes within and between groups were analyzed using repeated-measures analysis of covariance, with baseline disability as a covariate. Results Repeated measures analysis of covariance revealed no significant changes in gluteal muscle volume in either group. Significant decreases in IMF were observed in the gluteus maximus (-2.56 [95%CI: -4.47 to -0.64], p = 0.01) and gluteus medius (-1.00 [95%CI: -1.97 to -0.04], p = 0.04) in the AT group, with no significant changes in the SC group. Both groups demonstrated significant increases in gluteal maximus (AT:55.20 [95%CI: 31.84 to 78.55], p < 0.001; SC:41.45 [95%CI: 16.52 to 66.38], p = 0.002) and medius (AT:72.34 [95%CI: 44.62 to 100.05], p < 0.001; SC:43.91 [95%CI: 14.32 to 73.49], p = 0.005) strength. Improvements in gluteus IMF were moderately correlated with increases in physical quality of life (gluteus maximus: r=-0.33; gluteus medius: r=-0.31) and decreases in pain catastrophizing (gluteus minimus: r = 0.39). Conclusion The AT group demonstrated significant improvements in strength and IMF content, suggesting potential musculoskeletal benefits health in individuals with cLBP. Trial registration This study was registered at ClinicalTrials.gov (NCT05823857 on 10/04/2023).

Introduction Exercise therapy is the most recommended treatment for chronic low back pain (LBP), with evidence supporting modest effects, likely due to the heterogeneity of patient presentations. Evidence suggests that matching individuals to the most appropriate exercise type could improve outcomes. Systematic reviews also emphasise that effective exercise interventions should be patient centred, target paraspinal muscle health and be of sufficient duration. This study addresses these gaps using a targeted care approach to identify a homogenous sample that is more likely to respond to our interventions. The inclusion of a sample with predominant nociceptive pain profile will be performed with the integration of the Pain and Disability Drivers Management Model (PDDM) and the Lumbar Spine Instability Questionnaire (LSIQ). The primary aim of this two-arm randomised controlled trial is to compare the effectiveness of motor control plus isolated lumbar extension exercises (MC+ILEX, arm 1) to free-weight resistance training (arm 2) in reducing LBP-related disability. Secondary aims include examining whether changes in multifidus composition mediate disability improvements comparing intervention effects on muscle size and quality, strength, mobility, pain, quality of life, sleep, physical activity and satisfaction; exploring baseline LSIQ scores and sex/gender as moderators of treatment response; and investigating participants’ perceptions and experiences of exercise therapy.Methods and analysis A total of 106 participants will be recruited through primary and secondary care and randomised (1:1) to receive either MC+ILEX or free-weight resistance training. Both groups will complete 48 exercise sessions over 16 weeks. The primary outcome will be disability at 16 weeks, measured by the Oswestry Disability Index. Secondary outcomes include multifidus muscle composition and size, lumbar and gluteal muscle strength, hip range of motion, pain, physical and mental function, satisfaction and recovery, health-related quality of life, sleep quality and physical activity levels. Linear mixed-effects models will be used to assess primary and secondary outcomes. Regression analyses will explore whether baseline LSIQ scores moderate treatment effects on multifidus composition and other outcomes. A subsample of participants will undergo semistructured interviews before and after the intervention to explore their illness perceptions, illness mindsets, perceptions of exercise therapy, as well as their experiences and satisfaction with the two exercise interventions. Reflexive thematic analysis will be used to analyse qualitative data.Ethics and dissemination This study received ethics approval from the Central Ethics Research Committee of the Quebec Minister of Health and Social Services (CCER-25-26-14). Results will be submitted to peer-reviewed journals and scientific meetings.Trial registration number ISRCTN14864451.

Background:The Athlete Fear-Avoidance Questionnaire (AFAQ) is a validated instrument that measures athletes' fear and avoidance behaviors after an injury, particularly regarding their sporting activities. Purpose:This study aimed to adapt and validate the AFAQ for Arabic-speaking recreational players (AFAQ-Arabic) after anterior cruciate ligament reconstruction (ACLR). Study Design:Cohort study; level of evidence: 3. Methods:The AFAQ underwent translation and cross-cultural adaptation according to the Beaton guidelines. A total of 104 male recreational players who had undergone ACLR completed the AFAQ-Arabic, the Fear-Avoidance Belief Questionnaire (FABQ), and the Numerical Pain Scale (NPS). To assess test-retest reliability, a subset of 38 recreational players were asked to complete the AFAQ-Arabic twice, 1 week apart. Statistical tests were conducted to test the internal consistency, reliability, and convergent validity of the AFAQ-Arabic. Results:The AFAQ-Arabic demonstrated high internal consistency (Cronbach alpha, 0.854) and excellent test-retest reliability (intraclass correlation coefficient, 0.885) (95% CI, 0.784-0.942; P < .001). Minimal floor (4.8% scoring the minimum) and ceiling effects (1% scoring the maximum) were observed. Convergent validity showed significant positive weak correlations between the AFAQ-Arabic and (1) the FABQ-Physical Activity (r = 0.340; P < .01), (2) the FABQ-Work (r = 0.272; P < .01), and (3) the NPS (r = 0.383; P < .01). Cross-cultural adaptation of the AFAQ-Arabic revealed linguistic and cultural relevance. Conclusion:Our study demonstrated that the AFAQ-Arabic was a reliable and valid tool for assessing fear avoidance in Arabic-speaking recreational players after ACLR. Future studies are needed to measure athlete fear-avoidance in injured Arabic-speaking athletes to understand its psychological aspects in rehabilitation and potentially aid in tailored interventions for improving outcomes.

BACKGROUND: Ultramarathons are increasingly popular. Low back pain is common among ultramarathon racers, yet the effects of extreme endurance running on the lumbar spine are largely unknown. CASE PRESENTATION: We aimed to describe changes in the lumbar spine of 1 male athlete with chronic low back pain after completing a 610-km, 9-day winter ultramarathon. Magnetic resonance imaging (MRI) was obtained before and after the race to evaluate intervertebral discs, facet joints, and paraspinal muscles from L1-L2 to L5-S1. OUTCOME: Postrace reductions in disc height and disc MRI T2 signal intensity were observed. Disc degeneration (Pfirrmann Grade IV) and early signs of disc desiccation were noted at L5-S1 and L4-L5, respectively. Increased facet joint effusion, decreased muscle cross-sectional area, and MRI fat-signal fraction were observed postrace at most levels. DISCUSSION: Minimal changes were observed in the lumbar spine of a single athlete, despite the extraordinary physiological demands of a 610-km winter ultramarathon. JOSPT Cases 2025;5(3):163-170. Epub 10 July 2025. doi:10.2519/josptcases.2025.0110

Background: Chronic low back pain (CLBP) patients present with morphological and functional deficits to the lumbar multifidus. Electromyostimulation (EMS) can be used to improve activation and strength in atrophied skeletal muscle, but its effect on multifidus morphology and function in CLBP patients is understudied. The aims of this study were to compare the effect of two EMS protocols on lumbar multifidus morphology, function, and patient-reported outcomes. Methods: Two-arm randomized control trial (RCT). Individuals with CLBP were randomized to receive either the ‘phasic’ or ‘combined’ muscle therapy protocol with the StimaWELL 120MTRS, a medium-frequency EMS device. T-tests and non-parametric equivalents were used to assess change in imaging-based outcomes, and a repeated-measures ANOVA was used for patient-reported outcomes. Results: Apart from a significant within-group decrease in fatty infiltration at left L5-S1 in the combined group (MD = −1.51, 95% CI = −2.79, −0.23, p = 0.024), results revealed no significant within- or between-group changes to multifidus morphology or function. Pairwise comparisons revealed that both groups experienced significant improvements in multiple pain outcome measures, with a significant group*time effect for LBP with sitting (p = 0.019) and pain interference (p = 0.032) in favor of the phasic group. Additionally, there were significant improvements in the phasic group in disability, pain interference, and pain catastrophizing (all p < 0.01). Conclusions: A 10-week EMS intervention produced no between-group differences in multifidus muscle morphology or function. Participants in both groups experienced significant improvements in a variety of patient-reported outcomes.

Low back pain (LBP) is a disabling disease and a public health concern. Aquatic exercise is an alternative form of exercise with less spinal loading and difficulty performing movements, benefiting those with pain-related fear. This study aimed to investigate the effect of an aquatic exercise program (SwimEx) versus standard care (SC) on lumbar paraspinal muscle volume and composition, strength and patient outcomes in individuals with chronic LBP. This randomized controlled trial included 34 participants with chronic LBP. Participants were randomly allocated to each group (SwimEx, n = 18; SC, n = 16) and underwent a 10-week supervised intervention program twice per week. Magnetic resonance imaging was performed at baseline and 10-weeks to examine the impact of each intervention on multifidus (MF) and erector spinae (ES) muscle volume (cm3) and fatty infiltration (% FI) at L1-L2, L2-L3, L3-L4, L4-L5, and L5-S1. Mixed model repeated measures ANCOVA revealed no significant time*group interactions for MF and ES volume and %FI. SwimEX had significant increases in MF volume at L2-L3 and L3-L4, and ES volume at L1-L2. Furthermore, SwimEX also had a significant increase in MF %FI at L2-L3. Both groups displayed significant increases in lumbar strength. Correlations between muscle morphology and patient outcomes showed improvements in MF volume were moderately correlated with an increase in physical quality of life and decrease in anxiety/depression. Interestingly, improvements in MF volume, MF %FI, and ES %FI, were each moderately correlated with a decrease in sleep disturbance. In conclusion, aquatic therapy may help increase lumbar paraspinal muscle volume and strength in participants with chronic LBP. Our findings support the notion that improvements in paraspinal muscle health are related to improvements in patient-reported outcomes. More imaging studies are required to examine the impact of exercise on overall paraspinal muscle health in chronic LBP and investigate these associations.

Study DesignProspective Randomized Controlled Trial.ObjectivesTo investigate the effect of combined motor control and isolated lumbar strengthening exercise (MC + ILEX) vs general exercise (GE) on upper lumbar paraspinal muscle volume and composition, strength and patient outcomes in individuals with chronic low back pain (LBP).Methods50 participants with nonspecific chronic LBP were randomly allocated (1:1) to each group (MC + ILEX or GE) and underwent a 12-week supervised intervention program 2 times per week. Magnetic resonance imaging was performed at baseline, 6-weeks and 12-weeks to examine the impact of each intervention on multifidus (MF) and erector spinae (ES) muscle volume (cm3) and fatty infiltration (%FI) at L1-L2, L2-L3 and L3-L4.ResultsOur results revealed no significant between-groups findings for MF and ES %FI and volume, and patient-reported psychosocial measures. However, both groups had significant within-groups decreases in MF %FI at L1-L2, L2-L3 and L3-L4, with concomitant decreases in MF volume at L1-L2 and L2-L3, and at L3-L4 in the GE group. Each group displayed significant improvements in Kinesiophobia, while only MC + ILEX had significant improvements in pain catastrophizing, anxiety, depression and sleep. Lastly, significant correlations were found between change in Kinesiophobia and upper lumbar MF %FI, and between change in strength and lower lumbar MF and ES size.ConclusionsBoth exercise interventions may help reduce upper lumbar MF %FI in individuals with chronic LBP, while MC + ILEX could significantly improve important patient outcomes. Our results support the idea that improvements in paraspinal muscle health associate with better patient outcomes. Further high-quality imaging studies are needed to explore these relationships.

This study examined the relationship between body composition and on-field, in-game physical performance in female collegiate soccer players. Body composition, including total mass, fat mass, and lean tissue mass for the lower extremities and total body, was measured in 10 starting players using dual energy x-ray absorptiometry (DXA). On-field, in-game physical performance was tracked via a global positioning system (GPS) over 14 regular-season games, measuring total distance and distance covered in six speed zones. Players covered 4544.7 ± 495.2 m in the first half of the game and significantly less distance in the second half (3356.5 ± 1211.7 m, p = 0.004). A repeated measures ANOVA revealed decreased distances in jogging, low-, and moderate-intensity running during the second half compared to the first half of the game (p < 0.001). Lower total-body fat mass, total-body fat percentage, and lower-extremities fat mass were correlated with greater distances at moderate- and high-intensity running during the second half and entire game (r values from −0.644 to −0.745, p < 0.01 to 0.04). These findings suggest that body composition can influence the distance covered at moderate- and high-intensity running speed during competitive games. Training strategies aimed at reducing fat mass and incorporating high-intensity training may benefit female soccer players and enhance team success.

Background: Assessing sport-related concussions in athletes presents challenges due to symptom variability. This study aimed to explore the relationship between acute concussion symptoms and athlete fear avoidance, pain catastrophizing, depression, and anxiety. Anxiety and depression have previously been associated with the number of symptoms after a concussion, but no prior research has examined the possible link between athlete fear avoidance and acute concussion symptoms. Methods: Thirty-four collegiate athletes (mean age = 20.9 ± 1.8 years) were assessed within 48 h of a concussion using the Sport Concussion Assessment Tool 5, Athlete Fear Avoidance Questionnaire (AFAQ), Pain Catastrophizing Scale, and Hospital Anxiety and Depression Scale. Results: Results showed a significant association between the athlete fear avoidance and the number of concussion symptoms (r = 0.493, p = 0.003), as well as depression and anxiety measured by HADS (r = 0.686, p < 0.001). Athlete fear avoidance and HADS scores were predictors of symptom severity, explaining 41% of the variance (p = 0.001). Athletes with higher fear avoidance tended to report more symptoms post concussion. Conclusions: This study underscores the link between athlete fear avoidance, anxiety, depression, and the severity of concussion symptoms. Administering the AFAQ to assess athlete fear avoidance at the initial assessment of a concussion may be helpful in interpreting the symptoms of an acute concussion.

Objective The purpose of our study was to assess the relationship between fear avoidance and acute concussion symptoms in athletes. Design A cross-sectional study. Setting On the respective college campuses. Participants We had 34 participants, with an average age of 20.9 ± 1.8 years old, including 23 males and 11 females. Interventions (or Assessment of Risk Factors) We assessed the athletes' concussions within 48 hrs using the SCAT5, pain catastrophizing using the Pain Catastrophizing Scale, fear avoidance using the Athlete Fear Avoidance Questionnaire (AFAQ), and anxiety and depression using the Hospital Anxiety and Depression Questionnaire (HADS). Outcome Measures The dependent variables were AFAQ score, HADS score and PCS score. Main Results Our participants suffered an average of 7.4 ± 5.1 symptoms and a 16.3 ± 17.0 symptom severity score. The total number of symptoms was significantly associated with the AFAQ score (r=0.493). Moreover, the symptom severity score was associated with the AFAQ score (r=0.481). The total number of symptoms and severity score were significantly associated with the HADS score (r=0.686 and r=0.602). The AFAQ score, HADS depression and HADS anxiety scores model was a significant predictor of the total number of symptoms reported on the SCAT5, accounting for 50.4% of the variance (p>0.001) as well as severity (p=0.001). Conclusions Our study identified a significant relationship between athlete fear avoidance, depression, and anxiety and the number of acute concussion symptoms in athletes. A higher fear avoidance means that patients report more symptoms, and this relationship could explain why there is variability in the reporting of concussion symptoms.

Background/Objectives: Individuals with chronic low back pain (CLBP) have altered lumbar multifidus stiffness properties compared to healthy controls. Although neuromuscular electrical stimulation (NMES) application to the multifidus might affect stiffness, this has never been investigated. The aims of this study were to examine the effect of a single NMES treatment on multifidus stiffness and pain intensity in CLBP patients. Methods: 30 participants (13 male, 17 female) were randomized to one of two intervention (‘phasic’ and ‘combined’) protocols with the StimaWELL 120MTRS system. Multifidus stiffness at L4 and L5 was measured via shear-wave elastography (SWE) at rest and in standing prior to, and 15 min after, a 20 min NMES treatment. Pain intensity was measured pre- and post-treatment with the numerical pain rating scale (NPRS). Results: There were significant increases in resting shear modulus at right L4 (p = 0.001) and bilaterally at L5 (p = 0.017; p = 0.020) in the ‘combined’ intervention group, and a significant between-group difference at right L4 (p < 0.001). There were significant decreases in standing shear modulus at right L4 (p = 0.015) and left L5 (p = 0.036) in the ‘combined’ intervention group, and a significant between-group difference at left L5 (p = 0.016). Both groups experienced significant decreases in pain intensity (MD combined group = 1.12, 95% CI [0.34, 1.90], p = 0.011) (MD phasic group = 1.42, 95% CI [0.68, 2.16], p = 0.001). Conclusions: There were multiple significant changes in multifidus stiffness in the combined group, but not in the phasic group. Both groups experienced significant decreases in low back pain intensity.

Background: Preliminary research suggests that acupuncture can improve cardiovascular function. The purpose of our study was to determine if electroacupuncture can improve performance and post-exercise recovery. Methods: Thirty-two healthy people participated in this study (14 men and 18 women, aged 23.6 ± 3.5 years). The first visit included baseline measurements. Then, the participants received daily electroacupuncture at acupuncture point PC6 for a week, followed by a second visit. Heart rate, perceived exertion, and systolic and diastolic blood pressure were measured before, during, and after a YMCA submaximal bike test. Results: The heart rate was significantly reduced during the final stage of the YMCA test (151.3 ± 7.0 to 146.7 ± 11.8; p = 0.013) on the second visit. The rate of perceived exertion was significantly lower during all stages in Visit 2 (average RPE Visit 2 = 10.71 ± 2.02; average RPE Visit 1 = 11.45 ± 1.98; p = 0.004). Systolic blood pressure significantly decreased during the 5 min post-test recovery (SBP Visit 2 = 116.9 ± 12.0; SBP Visit 1 = 145.7 ± 14.6, p < 0.05). Conclusions: A week of electroacupuncture at PC6 led to reduced heart rate and perceived exertion during exercise, making the workload feel less strenuous. Electroacupuncture at PC6 shows potential for increasing participation in physical activities by making them feel easier to accomplish.

Athletes are injured frequently and often take analgesic medication. Moreover, athletes commonly use non‐prescription topical and oral medications with little guidance. Despite wide use, relatively few studies exist on the efficacy of pain medication in injured athletes compared to a placebo.

Background Low back pain (LBP) is highly prevalent in athletes, with lumbar multifidus (LM) atrophy and increased LM cross-sectional area (CSA) reported in athletes with LBP. Decreased LM CSA and thickness have also been previously associated with lower limb injury (LLI) in athletes. Yet, previous research has only investigated connections between LM, LBP, and LLI in small samples of athletes in a single sport at a time. The current study aimed to (1) examine LM morphology and function across a general sample of male and female university level varsity athletes; (2) investigate whether LM characteristics were predictors of LBP and LLI. Methods Exclusion criteria included previous severe spinal trauma or spinal fracture, spinal surgery, observable spinal abnormalities, and pregnancy. Ultrasound images of LM at L5 were acquired in prone and standing. Body composition was assessed with DEXA and a self-reported questionnaire provided demographics and history of injury. Paired t-tests and independent t-tests compared LM measurements between the sides and sex, respectively. Univariate and multivariate logistic regression analyses were used to assess if LM characteristics were predictors of LBP and LLI. Results 134 university varsity athletes (mean age, 21.0 ± 1.5, 84 male) were evaluated. LM CSA was larger on the non-dominant side in both males (non-dominant, 10.54 ± 1.55, dominant, 10.34 ± 1.58, p < 0.05) and females (non-dominant, 8.26 ± 1.32, dominant, 8.11 ± 1.33, p < 0.05) in prone. Increased LM thickness was associated with decreased odds of LBP in the previous 4-week (OR = 0.49 [0.27, 0.88], p = 0.02) and 3-month (OR = 0.43 [0.21, 0.89], p = 0.02) in the multivariable model, while a greater number of years playing at the university level was associated with increased odds of LBP (OR = 1.29 [1.01, 1.65], p = 0.04). Greater LM CSA asymmetry (OR = 1.14 [1.01, 1.28], p = 0.03) and sport (OR = 1.44 [1.04, 1.96], p = 0.02) were significant predictors of LLI in the previous 12 months. Conclusion Leg dominance may play a role in unilateral differences. LM thickness and LM CSA asymmetry were predictors of injury. Preseason screening of LM morphology and function could help identify athletes at risk of LBP and LLI. This could allow coaches, medical staff, and strength and conditioning staff to target these individuals and provide specific injury prevention programs.