The Effect of Beetroot Ingestion on High-Intensity Interval Training: A Systematic Review and Meta-Analysis.

Dietary nitrate supplementation has shown promising ergogenic effects on endurance exercise. However, at present there is no systematic analysis evaluating the effects of acute or chronic nitrate supplementation on performance measures during high-intensity interval training (HIIT) and sprint interval training (SIT). The main aim of this systematic review and meta-analysis was to evaluate the evidence for supplementation of dietary beetroot-a common source of nitrate-to improve peak and mean power output during HIIT and SIT. A systematic literature search was carried out following PRISMA guidelines and the PICOS framework within the following databases: PubMed, ProQuest, ScienceDirect, and SPORTDiscus. Search terms used were: ((nitrate OR nitrite OR beetroot) AND (HIIT or high intensity or sprint interval or SIT) AND (performance)). A total of 17 studies were included and reviewed independently. Seven studies applied an acute supplementation strategy and ten studies applied chronic supplementation. The standardised mean difference for mean power output showed an overall trivial, non-significant effect in favour of placebo (Hedges' g = -0.05, 95% CI -0.32 to 0.21, Z = 0.39, p = 0.69). The standardised mean difference for peak power output showed a trivial, non-significant effect in favour of the beetroot juice intervention (Hedges' g = 0.08, 95% CI -0.14 to 0.30, Z = 0.72, p = 0.47). The present meta-analysis showed trivial statistical heterogeneity in power output, but the variation in the exercise protocols, nitrate dosage, type of beetroot products, supplementation strategy, and duration among studies restricted a firm conclusion of the effect of beetroot supplementation on HIIT performance. Our findings suggest that beetroot supplementation offers no significant improvement to peak or mean power output during HIIT or SIT. Future research could further examine the ergogenic potential by optimising the beetroot supplementation strategy in terms of dosage, timing, and type of beetroot product. The potential combined effect of other ingredients in the beetroot products should not be undermined. Finally, a chronic supplementation protocol with a higher beetroot dosage (>12.9 mmol/day for 6 days) is recommended for future HIIT and SIT study.

Factors influencing providers' decisions on management of bone health in people with spinal cord injury.

STUDY DESIGN: Survey. OBJECTIVES: Managing osteoporosis in persons with chronic spinal cord injury (SCI) is difficult as little evidence exists regarding effective strategies. We examined the effect of key factors on providers' bone health management decisions in persons with SCI. SETTING: USA. METHODS: Providers reviewed blocks of 9 hypothetical cases that varied on four factors: osteoporosis, osteopenia, or normal bone mineral density using dual-energy X-ray absorptiometry (DXA); DXA region of interest (lumbar spine, hip, knee), prior lower extremity fracture; and no or limited ambulation. They indicated how likely they would recommend pharmacological management, what treatment(s) they would recommend, and whether they would request another DXA before treatment. RESULTS: Eighty-two healthcare providers completed the survey. Treatment recommendations for bisphosphonates and Vitamin D/calcium supplements, respectively, were more likely if there was a prior fracture (OR: 2.65, 95%CI: 1.76-3.99, p < 0.0001; OR: 2.96, 95%CI: 1.40-6.26, p = 0.004) and if a DXA scan found osteopenia (OR: 2.23, 95%CI: 1.41-3.54, p = 0.001; OR: 6.56, 95%CI: 2.71-15.85, p < 0.0001) or osteoporosis (OR: 12.08, 95%CI: 7.09-20.57, p < 0.0001; OR: 4.54, 95%CI: 2.08-9.90, p < 0.0001). Another DXA scan was more likely to be requested if there was a prior fracture (OR: 1.75, 95%CI: 1.10-2.78, p = 0.02) but less likely if the person was nonambulatory (OR: 0.41, 95%: 0.19-0.90, p = 0.03). CONCLUSIONS: Prior fracture and DXA findings influenced treatment recommendations for bone health management in SCI. Reliance on lumbar spine scans to determine bone loss and treatment identifies a knowledge gap for which future education is required.

Effect of Post-Exercise Massage on Passive Muscle Stiffness Measured Using Myotonometry - A Double-Blind Study.

It is commonly believed that massage can reduce muscle stiffness and is desirable for recovery from exercise. However, the effect massage on muscle stiffness following eccentric exercises is currently unknown. This study aimed to examine the effect of post-exercise massage on passive muscle stiffness over a five-day period. A randomised cross-over study design was adopted. After 40 minutes of downhill running, 18 male recreational runners had one leg received a 16-minute massage and the contralateral leg received a 16-minute sham ultrasound treatment. Passive stiffness for four leg muscles (rectus femoris, biceps femoris, tibialis anterior, and gastrocnemius) was assessed using myotonometry at baseline, immediately post-run, post-treatment, 24, 48, 72, and 96 hours post-run. A 2 (treatment) × 7 (time) mixed ANOVA was conducted with a robust procedure on the myotonometry data of each leg muscle to examine the effect of treatment on stiffness. Passive stiffness for all muscles changed over time but no treatment effect was found. Stiffness increased at 24 hours post-run and remained elevated from baseline levels for up to 96 hours across all four muscles. Significant treatment × time interaction was only found in the tibialis anterior but no post-hoc differences were identified. Passive stiffness of major leg muscles increased after a bout of unaccustomed eccentric exercise and remained elevated for up to four days post-exercise. Compared with the placebo treatment, post-exercise massage had no beneficial effect in alleviating altered muscle stiffness in major leg muscles.

Building Capacity for Complementary and Integrative Medicine Through a Large, Cross-Agency, Acupuncture Training Program: Lessons Learned from a Military Health System and Veterans Health Administration Joint Initiative Project.

Introduction: Complementary and integrative medicine (CIM) use in the USA continues to expand, including within the Military Health System (MHS) and Veterans Health Administration (VHA). To mitigate the opioid crisis and provide additional non-pharmacological pain management options, a large cross-agency collaborative project sought to develop and implement a systems-wide curriculum, entitled Acupuncture Training Across Clinical Settings (ATACS). Materials and Methods: ATACS curriculum content and structure were created and refined over the course of the project in response to consultations with Subject Matter Experts and provider feedback. Course content was developed to be applicable to the MHS and VHA environments and training was open to many types of providers. Training included a 4-hr didactic and "hands on" clinical training program focused on a single auricular acupuncture protocol, Battlefield Acupuncture. Trainee learning and skills proficiency were evaluated by trainer-observation and written examination. Immediately following training, providers completed an evaluation survey on their ATACS experience. One month later, they were asked to complete another survey regarding their auricular acupuncture use and barriers to use. The present evaluation describes the ATACS curriculum, faculty and trainee characteristics, as well as trainee and program developer perspectives. Results: Over the course of a 19-mo period, 2,712 providers completed the in-person, 4-hr didactic and hands-on clinical training session. Due to the increasing requests for training, additional ATACS faculty were trained. Overall, 113 providers were approved to be training faculty. Responses from the trainee surveys indicated high satisfaction with the ATACS training program and illuminated several challenges to using auricular acupuncture with patients. The most common reported barrier to using auricular acupuncture was the lack of obtaining privileges to administer auricular acupuncture within clinical practice. Conclusion: The ATACS program provided a foundational template to increase CIM across the MHS and VHA. The lessons learned in the program's implementation will aid future CIM training programs and improve program evaluations. Future work is needed to determine the most efficient means of improving CIM credentialing and privileging procedures, standardizing and adopting uniform CIM EHR codes and documentation, and examining the effectiveness of CIM techniques in real-world settings.

Effects of Caffeine Supplementation on Performance in Ball Games.

Although a large body of evidence exists documenting the ergogenic properties of caffeine, most studies have focused on endurance performance. However, findings from endurance sports cannot be generalized to performance in ball games where, apart from having a high level of endurance, successful athletic performances require a combination of physiological, technical and cognitive capabilities. The purpose of this review was to critically evaluate studies that have examined the effect of a single dose of caffeine in isolation on one or more of the following performance measures: total distance, sprint performance, agility, vertical jump performance and accuracy in ball games. Searches of three major databases resulted in 19 studies (invasion games: 13; net-barrier games: 6) that evaluated the acute effects of caffeine on human participants, provided the caffeine dose administered, and included a ball games specific task or simulated match. Improvements in sprint performance were observed in 8 of 10 studies (80%), and vertical jump in 7 of 8 studies (88%). Equivocal results were reported for distance covered, agility and accuracy. Minor side effects were reported in 4 of 19 studies reviewed. Pre-exercise caffeine ingestion between 3.0 and 6.0 mg/kg of body mass appears to be a safe ergogenic aid for athletes in ball games. However, the efficacy of caffeine varies depending on various factors, including, but not limited to, the nature of the game, physical status and caffeine habituation. More research is warranted to clarify the effects of caffeine on performance measures unique to ball games, such as agility and accuracy. It is essential that athletes, coaches and practitioners evaluate the risk-benefit ratio of caffeine ingestion strategies on an individual case-by-case basis.

A retrospective review of lower extremity fracture care in patients with spinal cord injury.

CONTEXT/OBJECTIVE: To identify circumstances surrounding incident lower extremity fractures (ILEFs) in patients with spinal cord injury (SCI) and to describe the impact of these fractures on service needs and provision of pharmacological therapies for osteoporosis. DESIGN: Retrospective medical record review. SETTING: Four Veterans Affairs Medical Centers in the USA. PARTICIPANTS: One hundred and forty patients with traumatic SCI who sustained an ILEF from 2002 to 2007. OUTCOME MEASURES: Fracture circumstances and use of assistive devices were described using percentages, means, and standard deviations. Fisher's exact test was used to determine the relationship between fracture site, and patient age and duration of SCI. Differences in pharmacological provision of therapies for osteoporosis pre- and post-fracture were examined using exact McNemar's test. RESULTS: One hundred and fifty-five ILEFs were identified in 140 patients. Tibia/fibula and femur fractures were the most common fractures. Fracture site was not related to patient's age or duration of SCI. Almost one-third of all fractures occurred during transfers to and from wheelchairs. Post-fracture, the provision of new or modified assistive devices, primarily wheelchairs, was frequent, occurring in 83% of patients in the year post-fracture. Few patients transferred residence to a nursing home following the fracture. There was a significant difference in the use of pharmacological therapies for osteoporosis in the first year post-fracture compared with the year prior to the fracture (P < 0.01), with significant differences in the volume of prescriptions for calcium supplements (P < 0.01) and bisphosphonates (P = 0.02). Overall, the amount of prescriptions for osteoporosis increased the year post-fracture (56%) from the year pre-fracture (39%); this increase was secondary to increases in prescriptions for calcium supplements (pre = 13%; post = 30%) and bisphosphonates (pre = 2%; post = 7%). CONCLUSIONS: We have identified that wheelchair and other transfer activities are a key area that could be a focus of fracture prevention in SCI. The need for new or modified assistive devices and/or wheelchair skills retraining post-fracture should be anticipated. Examination of whether treatments for osteoporosis following a fracture can prevent future osteoporotic fractures is warranted.

Adverse events in cardiovascular-related training programs in people with spinal cord injury: a systematic review.

CONTEXT: There are anecdotal reports of adverse events (AEs) associated with exercise in people with spinal cord injury (SCI) and consequent concern by people with SCI and their providers about potential risks of exercise. Enumeration of specific events has never been performed and the extent of risk of exercise to people with SCI is not understood. OBJECTIVE: To systematically review published evidence to identify and enumerate reports of adverse events or AEs associated with training in persons with SCI. METHODS: Review was limited to peer-reviewed studies published in English from 1970 to 2011: (1) in adults with SCI, (2) evaluating training protocols consisting of repeated sessions over at least 4 weeks to maintain or improve cardiovascular health, (3) including volitional exercise modalities and functional electrical stimulation (FES)-enhanced exercise modalities, and (4) including a specific statement about AEs. Trained reviewers initially identified a total of 145 studies. After further screening, 38 studies were included in the review. Quality of evidence was evaluated using established procedures. RESULTS: There were no serious AEs reported. There were no common AEs reported across most types of interventions, except for musculoskeletal AEs related to FES walking. There were few AEs in volitional exercise studies. CONCLUSION: There is no evidence to suggest that cardiovascular exercise done according to guidelines and established safety precautions is harmful. To improve the strength of these conclusions, future publications should include definition of AEs, information about pre-intervention screening, and statements of the nature and extent of AEs.

Beneficial effects of combined olive oil ingestion and acute exercise on postprandial TAG concentrations in healthy young women.

Foods high in monounsaturated fat, such as olive oil, and endurance exercise are both known to independently reduce postprandial TAG concentrations. We examined the combined effects of exercise and dietary fat composition on postprandial TAG concentrations in nine healthy pre-menopausal females (age 26·8 (sd 3·3) years, BMI 22·3 (sd 2·0) kg/m2). Each participant completed four, 2 d trials in a randomised order: (1) butter-no exercise, (2) olive oil-no exercise, (3) butter-exercise, (4) olive oil-exercise. On day 1 of the exercise trials, participants walked or ran on a treadmill for 60 min. On the no-exercise trials, participants rested on day 1. On day 2 of each trial, participants rested and consumed an olive oil meal (saturated fat 15 % and unsaturated fat 85 %) or a butter meal (saturated fat 71 % and unsaturated fat 29 %) for breakfast. Venous blood samples were obtained in the fasted state and for 6 h postprandially on day 2. A significant main effect on physical activity (exercise or control) was obtained for plasma TAG concentration (three-way ANOVA, P = 0·043), and the total area under the concentration v. time curve for TAG was 26 % lower on the olive oil-exercise trial (4·40 (sd 0·40) mmol × 6 h/l) than the butter-no exercise trial (5·91 (sd 1·01) mmol × 6 h/l) (one-way ANOVA, P = 0·029). These findings suggest that the combination of exercise and a preference for monounsaturated dietary fat intake in the form of olive oil may be most beneficial for reducing postprandial TAG concentrations.

Knowledge and use of antimicrobial stewardship resources by spinal cord injury providers.

OBJECTIVE: To assess the knowledge and the use of antimicrobial stewardship resources, such as hospital antibiograms and infectious disease consultants, by spinal cord injury or disorder (SCI/D) providers. DESIGN AND SETTING: Anonymous Internet-based, cross-sectional survey. PARTICIPANTS: A total of 314 SCI/D physicians, nurse practitioners, and physician assistants who prescribe antibiotics were invited to complete a survey. MAIN OUTCOME MEASUREMENTS: Knowledge of and behaviors related to antibiograms and infectious disease (ID) consults. RESULTS: A total of 118 providers (80 physicians, 20 nurse practitioners, 18 physician assistants) completed the survey (37.6% response rate). Approximately one-third of respondents indicated that they did not have access to (11.0%) or were unsure of (28.0%) the existence of facility antibiograms. Half of the providers indicated that they never used antibiograms to determine treatment for their SCI/D patients. Respondent factors associated with viewing facility antibiograms were older age, employment at SCI/D specialty centers, a longer duration since completion of training, and years of SCI/D patient care. Nearly all respondents (95%) indicated that they believed that improving access to antibiotic prescribing data or antibiograms would reduce antibiotic resistance. More than one-third reported that they never or seldom used ID consults. CONCLUSIONS: A significant portion of SCI/D providers who prescribe antibiotics do not have access to facility antibiograms or are unaware of their existence and thus could not use them for determining antibiotic treatment. Interventions could include formal education of providers on how to access antibiograms and the use of ID physicians as a resource, as well as providing technologic support, such as electronic facility-level antibiograms as part of the medical record system, which can be easily identified if a provider is making a decision on an antibiotic.

The feasibility of hypnotic analgesia in ameliorating pain and anxiety among adults undergoing needle electromyography.

OBJECTIVE: Our hypothesis was that hypnotic analgesia reduces pain and anxiety during electromyography (EMG). DESIGN: We performed a prospective randomized, controlled clinical trial at outpatient electrodiagnostic clinics in teaching hospitals. Just before EMG, 26 subjects were randomized to one of three 20-min audio programs: education about EMG (EDU) (n = 8); hypnotic induction without analgesic suggestion (n = 10); or hypnotic induction with analgesic suggestion (n = 8). The blinded electromyographer provided a posthypnotic suggestion at the start of EMG. After EMG, subjects rated worst and average pain and anxiety using visual analog scales. RESULTS: Mean values for the EDU, hypnotic induction without analgesic suggestion, and hypnotic induction with analgesic suggestion groups were not significantly different (mean +/- SD): worst pain 67 +/- 25, 42 +/- 18, and 49 +/- 30; average pain 35 +/- 26, 27 +/- 14, and 25 +/- 22; and anxiety 44 +/- 41, 42 +/- 23, and 22 +/- 24. When hypnosis groups were merged (n = 18) and compared with the EDU condition (n = 8), average and worst pain and anxiety were less for the hypnosis group than EDU, but this was statistically significant only for worst pain (hypnosis, 46 +/- 24 vs. EDU, 67 +/- 35; P = 0.049) with a 31% average reduction. CONCLUSIONS: A short hypnotic induction seems to reduce worst pain during electromyography.

Auricular acupuncture in the treatment of acute pain syndromes: A pilot study.

This pilot study used a randomized controlled clinical trial design to compare the effects of standard emergency medical care to auricular acupuncture plus standard emergency medical care in patients with acute pain syndromes. Eighty-seven active duty military personnel and their dependents with a diagnosis of acute pain completed the study, which was conducted in the emergency room (ER) at Malcolm Grow Medical Center, Andrews Air Force Base, Maryland. The primary outcome measure was change in pain level from baseline, as measured by the Numerical Rating Scale. Participants in the acupuncture group experienced a 23% reduction in pain before leaving the ER, while average pain levels in participants in the standard medical care group remained basically unchanged. (p < 0.0005). However, both groups experienced a similar reduction in pain 24 hours following treatment in the ER. More research is needed to elucidate treatment effects and to determine mechanisms.