Non-invasive prehabilitation to foster widespread fMRI cortical reorganization before brain tumor surgery: lessons from a case series.

PURPOSE: The objective of this prospective, single-centre case series was to investigate feasibility, clinical outcomes, and neural correlates of non-invasive Neuromodulation-Induced Cortical Prehabilitation (NICP) before brain tumor surgery. Previous studies have shown that gross total resection is paramount to increase life expectancy but is counterbalanced by the need of preserving critical functional areas. NICP aims at expanding functional margins for extensive tumor resection without functional sequelae. Invasive NICP (intracranial neuromodulation) was effective but characterized by elevated costs and high rate of adverse events. Non-invasive NICP (transcranial neuromodulation) may represent a more feasible alternative. Nonetheless, up to this point, non-invasive NICP has been examined in only two case reports, yielding inconclusive findings. METHODS: Treatment sessions consisted of non-invasive neuromodulation, to transiently deactivate critical areas adjacent to the lesion, coupled with intensive functional training, to activate alternative nodes within the same functional network. Patients were evaluated pre-NICP, post-NICP, and at follow-up post-surgery. RESULTS: Ten patients performed the intervention. Feasibility criteria were met (retention, adherence, safety, and patient's satisfaction). Clinical outcomes showed overall stability and improvements in motor and executive function from pre- to post-NICP, and at follow-up. Relevant plasticity changes (increase in the distance between tumor and critical area) were observed when the neuromodulation target was guided by functional neuroimaging data. CONCLUSION: This is the first case series demonstrating feasibility of non-invasive NICP. Neural correlates indicate that neuroimaging-guided target selection may represent a valid strategy to leverage neuroplastic changes before neurosurgery. Further investigations are needed to confirm such preliminary findings.

STORMS: A Pilot Feasibility Study for Occupational TeleRehabilitation in Multiple Sclerosis.

Digital solutions in the field of restorative neurology offer significant assistance, enabling patients to engage in rehabilitation activities remotely. This research introduces ReMoVES, an Internet of Medical Things (IoMT) system delivering telemedicine services specifically tailored for multiple sclerosis rehabilitation, within the overarching framework of the STORMS project. The ReMoVES platform facilitates the provision of a rehabilitative exercise protocol, seamlessly integrated into the Individual Rehabilitation Project, curated by a multidimensional medical team operating remotely. This manuscript delves into the second phase of the STORMS pilot feasibility study, elucidating the technology employed, the outcomes achieved, and the practical, professional, and academic implications. The STORMS initiative, as the genesis of digital telerehabilitation solutions, aims to enhance the quality of life for multiple sclerosis patients.

Optimizing athletic performance through advanced nutrition strategies: can AI and digital platforms have a role in ultraendurance sports?

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

Development and Rasch Validation of an Observational Assessment Tool of Upper Limb Functional Impairment in Stroke Survivors: Functional Assessment Test for Upper Limb.

OBJECTIVE: To develop and validate a quick observational clinical tool, the Functional ASsessment Test for Upper Limb (FAST-UL), for the evaluation of upper limb impairment in goal-directed functional-oriented motor tasks after stroke. DESIGN: Observational, cross-sectional, psychometric study. SETTING: Inpatient and outpatient rehabilitation clinic. PARTICIPANTS: A total of 188 post-stroke survivors (mean age 65.2±17.7 years, 61% men, 48% with ischemic stroke and 66% in the sub-acute phase; N=188). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Principal component analysis and Rasch analysis through a Partial Credit Model were used to assess the structure and psychometric properties of the 5 items of the FAST-UL (Hand to Mouth [HtM], Reach to Target, Prono-Supination, Grasp and Release, and Pinch and Release [PaR]). RESULTS: The Cronbach's α equal to 0.96 was indicative of an acceptable internal consistency; the reliability, as measured through the Person Separation Reliability equal to 0.87, was good. The FAST-UL tool was unidimensional. All the FAST-UL items were found to fit well the Rasch measurement model. The easiest to perform FAST-UL item was the HtM movement while the most difficult was the PaR movement. CONCLUSIONS: The FAST-UL is a quick, easy-to-administer observational assessment tool of upper limb motor impairment in post-stroke survivors with good item-level psychometric properties.

The Effect of Verbal Encouragement on Performance and Muscle Fatigue in Swimming.

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

Dual task gait deteriorates gait performance in cervical dystonia patients: a pilot study.

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

I can't count, but I can beat you playing cards: a case report on autoimmune encephalitis.

BACKGROUND: Autoimmune encephalitis (AE) is a rare inflammatory disorder characterized by important psychiatric and neurologic symptoms. The literature documents high rates of neuropsychological dysfunction in N-methyl D-aspartate-receptor (NMDAr) encephalitis but papers don't consider specifically calculation disturbances between the long-term deficits, although deficits in executive control and episodic memory were less likely to resolve. CASE REPORT: Here we present a severe case of NMDAr encephalitis in a young patient without a relevant past medical history. Upon first examination he presented psycho-motor slowdown, speech disorders, severe cognitive deficits in all areas: concentration, attention, memory, language, dual task functions, increased latency in responses, severe dyscalculia. Upon first evaluation, the young patient underwent a battery of neuropsychological tests and he showed a dysexecutive syndrome with performances significantly low for age and education. Our patient hence underwent 1 month of intensive cognitive rehabilitation. After the rehabilitation treatment, he presented an amelioration in all domains except calculations. CONCLUSIONS: In our patient the calculation disorder has proved to be the most relevant problem and the most difficult to treat. Clinicians should consider a careful approach to determine the prognosis of this syndrome because of the wide range of deficits, the need of prolonged treatment and the rate of long-term sequelae.

Improved visuospatial neglect after tDCS and computer-assisted cognitive training in Posterior Cortical Atrophy: a single-case study.

Visuospatial neglect (VN) frequently occurs in Posterior Cortical Atrophy (PCA) and requires specific rehabilitation. In this single-case study, we investigated the efficacy of a computer-assisted cognitive training (CCT) alone or coupled with multiple sessions of anodal transcranial direct-current stimulation (A-tDCS) over the right posterior parietal cortex in improving left VN symptoms in a patient with PCA. The digital ReMoVES platform was used for both VN assessment and training. We found a significant improvement after CCT combined with A-tDCS within the limits of a single-case, our results suggest, for the first time, the usefulness of this combined approach in a neurodegenerative disorder.

A Study Protocol for Occupational Rehabilitation in Multiple Sclerosis.

Digital medical solutions can be very helpful in restorative neurology, as they allow the patients to practice their rehabilitation activities remotely. This work discloses ReMoVES, an IoMT system providing telemedicine services, in the context of Multiple Sclerosis rehabilitation, within the frame of the project STORMS. A rehabilitative protocol of exercises can be provided as ReMoVES services and integrated into the Individual Rehabilitation Project as designed by a remote multidimensional medical team. In the present manuscript, the first phase of the study is described, including the definition of the needs to be addressed, the employed technology, the design and the development of the exergames, and the possible practical/professional and academic consequences. The STORMS project has been implemented with the aim to act as a starting point for the development of digital telerehabilitation solutions that support Multiple Sclerosis patients, improving their living conditions. This paper introduces a study protocol and it addresses pre-clinical research needs, where system issues can be studied and better understood how they might be addressed. It also includes tools to favor remote patient monitoring and to support the clinical staff.

Habituation of Somatosensory Evoked Potentials in Patients with Alzheimer's Disease and Those with Vascular Dementia.

Background and Objectives: The most prevalent dementia are Alzheimer's disease and vascular dementia. There is evidence that cortical synaptic function may differ in these two conditions. Habituation of cortical responses to repeated stimuli is a well-preserved phenomenon in a normal brain cortex, related to an underlying mechanism of synaptic efficacy regulation. Lack of habituation represents a marker of synaptic dysfunction. The purpose of this study was to assess the habituation of somatosensory evoked potentials (SEPs) in 29 patients affected by mild-to-moderate Alzheimer's disease (AD-type) or vascular (VD-type) dementia. Materials and Methods: All patients underwent a clinical history interview, neuropsychological evaluation, and neuroimaging examination. SEPs were elicited by electrical stimulation of the right median nerve at the wrist. Six-hundred stimuli were delivered, and cortical responses divided in three blocks of 200. Habituation was calculated by measuring changes of N20 amplitude from block 1 to block 3. SEP variables recorded in patients were compared with those recorded in 15 age- and gender-matched healthy volunteers. Results: SEP recordings showed similar N20 amplitudes in AD-type and VD-type patients in block 1, that were higher than those recorded in controls. N20 amplitude decreased from block 1 to block 3 (habituation) in normal subjects and in VD-type patients, whereas in AD-type patients it remained unchanged (lack of habituation). Conclusions: The findings suggest that neurophysiologic mechanisms of synaptic efficacy that underneath habituation are impaired in patients with AD-type dementia but not in patients with VD-type dementia. SEPs habituation may contribute to early distinction of Alzheimer's disease vs. vascular dementia.

Effects of Cerebellar tDCS on Inhibitory Control: Evidence from a Go/NoGo Task.

Response inhibition as an executive function refers to the ability to suppress inappropriate but prepotent responses. Several brain regions have been implicated in the process underlying inhibitory control, including the cerebellum. The aim of the present study was to explore the role of the cerebellum in executive functioning, particularly in response inhibition. For this purpose, we transitorily inhibited cerebellar activity by means of cathodal tDCS and studied the effects of this inhibition on ERP components elicited during a Go/NoGo task in healthy subjects. Sixteen healthy subjects underwent a Go/NoGo task prior to and after cathodal and sham cerebellar tDCS in separate sessions. A reduction in N2-NoGo amplitude and a prolongation in N2-NoGo latency emerged after cathodal tDCS whereas no differences were detected after sham stimulation. Moreover, commission errors in NoGo trials were significantly higher after cathodal tDCS than at the basal evaluation. No differences emerged between performances in Go trials and those after sham stimulation. These data indicate that cerebellar inhibition following cathodal stimulation alters the ability to allocate attentional resources to stimuli containing conflict information and the inhibitory control. The cerebellum may regulate the attentional mechanisms of stimulus orientation and inhibitory control both directly, by making predictions of errors or behaviors related to errors, and indirectly, by controlling the functioning of the cerebral cortical areas involved in the perception of conflict signals and of the basal ganglia involved in the inhibitory control of movement.

Electromyographic assessment of paratonia.

Many years after its initial description, paratonia remains a poorly understood concept. It is described as the inability to relax muscles during muscle tone assessment with the subject involuntary facilitating or opposing the examiner. Although related to cognitive impairment and frontal lobe function, the underlying mechanisms have not been clarified. Moreover, criteria to distinguish oppositional paratonia from parkinsonian rigidity or spasticity are not yet available. Paratonia is very frequently encountered in clinical practice and only semi-quantitative rating scales are available. The purpose of this study is to assess the feasibility of a quantitative measure of paratonia using surface electromyography. Paratonia was elicited by performing consecutive metronome-synchronized continuous and discontinuous elbow movements in a group of paratonic patients with cognitive impairment. Goniometric and electromyographic recordings were performed on biceps and triceps brachii muscles. Facilitatory (mitgehen) and oppositional (gegenhalten) paratonia could be recorded on both muscles. After normalization with voluntary maximal contraction, biceps showed higher paratonia than triceps. Facilitatory paratonia was higher than oppositional on the biceps. Movement repetition induced increased paratonic burst amplitude only when flexion and extension movements were performed continuously. Both facilitatory and oppositional paratonia increased with movement repetition. Only oppositional paratonia increased following faster movements. This is the first study providing a quantitative and objective characterization of paratonia using electromyography. Unlike parkinsonian rigidity, oppositional paratonia increases with velocity and with consecutive movement repetition. Like spasticity, oppositional paratonia is velocity-dependent, but different from spasticity, it increases during movement repetition instead of decreasing. A quantitative measure of paratonia could help better understanding its pathophysiology and could be used for research purposes on cognitive impairment.

Protocol for the study of self-perceived psychological and emotional well-being of young Paralympic athletes.

BACKGROUND: We present the detailed protocol set up to investigate how agonistic sport affects the self-perceived psychological and emotional well-being of disabled young people. METHODS: The study will be carried out on a number of subjects as large as 800-1200, using well-established indices that give a quantitative measure of such well-being, namely SF-12 and PGWBI. The related questionnaires will be administered to the participants to a forthcoming international event, the European Para-Youth Games, 9-15 October 2017, Liguria, Italy, as well as to a reference population of a similar number of subjects, made up of young disabled people that do not practice agonistic sport. DISCUSSION: We expect that the outcomes of the study may strongly impact not only the socio-sanitary field but also society in general, as disabled people can be considered an extreme situation in the issue of balancing individual needs and environment to pursue psychological well-being. TRIAL REGISTRATION: ISRCTN14389453 (29 June 2017).

Learning "How to Learn": Super Declarative Motor Learning Is Impaired in Parkinson's Disease.

Learning new information is crucial in daily activities and occurs continuously during a subject's lifetime. Retention of learned material is required for later recall and reuse, although learning capacity is limited and interference between consecutively learned information may occur. Learning processes are impaired in Parkinson's disease (PD); however, little is known about the processes related to retention and interference. The aim of this study is to investigate the retention and anterograde interference using a declarative sequence learning task in drug-naive patients in the disease's early stages. Eleven patients with PD and eleven age-matched controls learned a visuomotor sequence, SEQ1, during Day1; the following day, retention of SEQ1 was assessed and, immediately after, a new sequence of comparable complexity, SEQ2, was learned. The comparison of the learning rates of SEQ1 on Day1 and SEQ2 on Day2 assessed the anterograde interference of SEQ1 on SEQ2. We found that SEQ1 performance improved in both patients and controls on Day2. Surprisingly, controls learned SEQ2 better than SEQ1, suggesting the absence of anterograde interference and the occurrence of learning optimization, a process that we defined as "learning how to learn." Patients with PD lacked such improvement, suggesting defective performance optimization processes.

The effect of age on post-activation depression of the upper limb H-reflex.

PURPOSE: Post-activation depression (PaD) refers to the inhibition of the H-reflex induced by a preceding conditioning stimulus able to activate the afferents mediating the H-reflex itself. PaD can be investigated assessing the frequency-related depression of the H-reflex. This parameter, which is highly correlated to the severity of spasticity, has been used in the longitudinal assessment of spastic patients, in particular to assess the effect of drugs and rehabilitation over the years. However, in such longitudinal assessment, changes observed might be age related and not only disease related. The aim of this study was to investigate the possible age effects on PaD. METHODS: The frequency-related depression of the flexor carpi radialis (FCR) H-reflex was examined in two groups of young (20 subjects; 28 ± 3 years) and aged (18 subjects; 69 ± 6 years) healthy subjects. PaD was evaluated by comparing the H-reflex amplitudes obtained with a stimulation frequency of 0.1 Hz with those obtained using higher frequencies (0.33-0.5-1-2 Hz). RESULTS: The results showed that frequency-related depression of the FCR H-reflex is similar in young and elderly subjects at all frequencies, with the exception of 2 Hz. CONCLUSION: Our study shows that ageing does not affect the frequency-related depression of the FCR H-reflex at the frequencies of 1 Hz or lower, supporting the reliability of this method to assess PaD in the clinical practice, particularly for the longitudinal assessment of spasticity. A decrease of GABA-ergic presynaptic inhibition seems to be the more likely explanation for the age-related changes that we observed at the frequency of 2 Hz.

Upper Limbs Muscle Co-Contraction Changes Correlate With The Physical Motor Impairments in CMT.

Background: Subjects with Charcot-Marie-Tooth (CMT) disease show hands impairment which is a relevant problem affecting the quality of life. This symptom is related to muscle weakness and reduced motor coordination of the upper limb. However, most studies focus on lower limb impairment, therefore the investigation of upper limb disability is necessary to identify biomarkers able to monitor disease-specific features and to tailor rehabilitation. Objective: This study aimed at characterizing upper limb muscle co-contraction using the co-contraction index (CCI) in CMT population. Methods: Upper limb kinematic and electromyography (EMG) data were collected from fourteen CMT subjects (6-CMT1A and 8-CMT1X) during motor tasks typical of daily living activities. Rudolph's CCI was used to quantify muscle co-contraction of four muscle pairs acting on shoulder, elbow and wrist. All CMT subjects underwent clinical examination. Thirteen healthy subjects served as the normative reference (HC). Results: CMT1X and CMT1A showed a significant reduction in CCI for distal and proximal muscle pairs compared to HC. Furthermore, CMT1A showed greater values of CCI compared to CMT1X mainly for the axial and axial-to-proximal muscle pairs. Movement speed and smoothness were not altered compared to HC. In addition, EMG metrics showed moderate-to-strong significant correlations with clinical outcomes. Conclusions: CCI was able to quantify disease-specific deficits with respect to the normative reference, highlighting motor control alterations even before motor output impairment. CCI was also sensitive in detecting CMT subtypes-based differences and adopted compensatory strategies. Our findings suggest that CCI can be an outcome measure for CMT disease monitoring and interventional studies.

Improvement of Motor Task Performance: Effects of Verbal Encouragement and Music-Key Results from a Randomized Crossover Study with Electromyographic Data.

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

Adaptive Shooting Disciplines: A Scoping Review of the Literature with Bibliometric Analysis.

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