Moderate-intensity aerobic exercise training as an adjunct to trauma-focused psychotherapy in traumatized refugees and asylum seekers: study protocol of a randomized controlled trial.

Background: Refugees with exposure to multiple traumatic events are at high risk for developing posttraumatic stress disorder (PTSD) and depression. Narrative exposure therapy (NET) is an effective treatment for the core symptoms of PTSD, but it does not reliably reduce depressive symptoms. Endurance exercise on the other hand was consistently found to be effective in treating depression making it a promising adjunct to NET. Up to date, no studies exist investigating the combination of NET and endurance exercise in a sample of refugees with PTSD and comorbid depression.Objectives: In the proposed randomized controlled trial, we aim to investigate whether a combination of NET and moderate-intensity aerobic exercise training (MAET) enhances treatment outcome for refugees with PTSD and comorbid depressive symptoms. We expect a greater improvement in psychopathology in participants who receive the combined treatment.Methods and analysis: 68 refugees and asylum seekers with PTSD and clinically relevant depressive symptoms will be recruited in the proposed study. Participants will be randomly assigned to receive either NET only (NET-group) or NET plus MAET (NET+-group). All participants will receive 10 NET sessions. Participants in the NET+-group will additionally take part in MAET. Primary (PTSD, depression) and secondary (general mental distress, agoraphobia and somatoform complaints, sleep quality) outcome measures will be assessed before treatment, after treatment, and at six-month follow-up. The hypotheses will be tested with multiple 2 × 3 mixed ANOVA's.Trial registration: German Clinical Trials Register identifier: DRKS00022145.

Refugees are at particularly high risk of developing posttraumatic stress disorder and comorbid depressive symptoms due to exposure to multiple man-made traumatic events.Narrative exposure therapy reliably reduces symptoms of posttraumatic stress disorder, but many patients retain their clinical diagnosis, untreated comorbid depressive symptoms may interfere with treatment response.The randomized controlled trial aims to investigate whether combining narrative exposure therapy with moderate-intensity aerobic exercise training enhances treatment outcomes for refugees with posttraumatic stress disorder and comorbid depressive symptoms, compared to narrative exposure therapy as a stand-alone treatment.

Does Higher Intensity Increase the Rate of Responders to Endurance Training When Total Energy Expenditure Remains Constant? A Randomized Controlled Trial.

BACKGROUND: Standardized training prescriptions often result in large variation in training response with a substantial number of individuals that show little or no response at all. The present study examined whether the response in markers of cardiorespiratory fitness (CRF) to moderate intensity endurance training can be elevated by an increase in training intensity. METHODS: Thirty-one healthy, untrained participants (46 ± 8 years, BMI 25.4 ± 3.3 kg m-2 and [Formula: see text]O2max 34 ± 4 mL min-1 kg-1) trained for 10 weeks with moderate intensity (3 day week-1 for 50 min per session at 55% HRreserve). Hereafter, the allocation into two groups was performed by stratified randomization for age, gender and VO2max response. CON (continuous moderate intensity) trained for another 16 weeks at moderate intensity, INC (increased intensity) trained energy-equivalent for 8 weeks at 70% HRreserve and then performed high-intensity interval training (4 × 4) for another 8 weeks. Responders were identified as participants with VO2max increase above the technical measurement error. RESULTS: There was a significant difference in [Formula: see text]O2max response between INC (3.4 ± 2.7 mL kg-1 min-1) and CON (0.4 ± 2.9 mL kg-1 min-1) after 26 weeks of training (P = 0.020). After 10 weeks of moderate training, in total 16 of 31 participants were classified as VO2max responders (52%). After another 16 weeks continuous moderate intensity training, no further increase of responders was observed in CON. In contrast, the energy equivalent training with increasing training intensity in INC significantly (P = 0.031) increased the number of responders to 13 of 15 (87%). The energy equivalent higher training intensities increased the rate of responders more effectively than continued moderate training intensities (P = 0.012). CONCLUSION: High-intensity interval training increases the rate of response in VO2max to endurance training even when the total energy expenditure is held constant. Maintaining moderate endurance training intensities might not be the best choice to optimize training gains. Trial Registration German Clinical Trials Register, DRKS00031445, Registered 08 March 2023-Retrospectively registered, https://www.drks.de/DRKS00031445.

The association of end-spurt behaviour with seasonal best time in long-distance freestyle pool swimming.

To analyse the association of seasonal best time, distance and different performance levels with end-spurt behaviour in one swimming season. Race results in 800 and 1500 m pool freestyle swimming in the season 2018/2019 including 14,930 races and 2650 swimmers were obtained. The end-spurt for each race was determined by means of an End-Spurt Indicator (ESI). Subsequently, ESI was used as a dependent variable and influences were analysed using a linear mixed model with fixed effects for seasonal best time, distance, and performance level amongst others. In the 800 and 1500 m races swimmers showed a mean ESI of 2.08 (95% CI: 2.02-2.13) and 3.68 (95% CI: 3.59-3.76), respectively. There was a significant association between seasonal best time and ESI, with a better seasonal best time showing a greater ESI (F = 70.5, P < .001, f2 = 0.04). A significant effect on greater ESI was also observed for longer distance (F = 1067.5, P < .001, f2 = 0.06) and higher performance level (F = 91.1, P < .001, f2 = 0.02). Elite swimmers had a mean ESI of 5.47 (95% CI: 4.91-6.03), sub-elite swimmers of 3.74 (95% CI: 3.53-3.95) and competitive swimmers of 2.41 (95% CI: 2.37-2.46). A more pronounced end-spurt is associated with seasonal best time in long-distance pool swimming, higher performance level of the swimmer and longer race distance.

Effects on cardiorespiratory fitness of moderate-intensity training vs. energy-matched training with increasing intensity.

Introduction: The present study investigated the role of training intensity in the dose-response relationship between endurance training and cardiorespiratory fitness (CRF). The hypothesis was that beginners would benefit from an increase in training intensity after an initial training phase, even if the energy expenditure was not altered. For this purpose, 26 weeks of continuous moderate training (control group, CON) was compared to training with gradually increasing intensity (intervention group, INC) but constant energy expenditure. Methods: Thirty-one healthy, untrained subjects (13 men, 18 women; 46 ± 8 years; body mass index 25.4 ± 3.3 kg m-2; maximum oxygen uptake, VO2max 34 ± 4 ml min-1 kg-1) trained for 10 weeks with moderate intensity [3 days/week for 50 min/session at 55% heart rate reserve (HRreserve)] before allocation to one of two groups. A minimization technique was used to ensure homogeneous groups. While group CON continued with moderate intensity for 16 weeks, the INC group trained at 70% HRreserve for 8 weeks and thereafter participated in a 4 × 4 training program (high-intensity interval training, HIIT) for 8 weeks. Constant energy expenditure was ensured by indirect calorimetry and corresponding adjustment of the training volume. Treadmill tests were performed at baseline and after 10, 18, and 26 weeks. Results: The INC group showed improved VO2max (3.4 ± 2.7 ml kg-1 min-1) to a significantly greater degree than the CON group (0.4 ± 2.9 ml kg-1 min-1) (P = 0.020). In addition, the INC group exhibited improved Vmax (1.7 ± 0.7 km h-1) to a significantly greater degree than the CON group (1.0 ± 0.5 km h-1) (P = 0.001). The reduction of resting HR was significantly larger in the INC group (7 ± 4 bpm) than in the CON group (2 ± 6 bpm) (P = 0.001). The mean heart rate in the submaximal exercise test was reduced significantly in the CON group (5 ± 6 bpm; P = 0.007) and in the INC group (8 ± 7 bpm; P = 0.001), without a significant interaction between group and time point. Conclusion: Increasing intensity leads to greater adaptations in CRF than continuing with moderate intensity, even without increased energy expenditure. After 26 weeks of training in the moderate- and higher-intensity domain, energy-matched HIIT elicited further adaptations in cardiorespiratory fitness. Thus, training intensity plays a crucial role in the dose-response relationship between endurance training and fitness in untrained but healthy individuals. Clinical Trial Registration: https://www.drks.de/DRKS00031445, identifier DRKS00031445.

COVID-19 in German Competitive Sports: Protocol for a Prospective Multicenter Cohort Study (CoSmo-S).

Objective: It is unclear whether and to what extent COVID-19 infection poses health risks and a chronic impairment of performance in athletes. Identification of individual health risk is an important decision-making basis for managing the pandemic risk of infection with SARS-CoV-2 in sports and return to play (RTP). Methods: This study aims 1) to analyze the longitudinal rate of seroprevalence of SARS-CoV-2 in German athletes, 2) to assess health-related consequences in athletes infected with SARS-CoV-2, and 3) to reveal effects of the COVID-19 pandemic in general and of a cleared SARS-CoV-2 infection on exercise performance. CoSmo-S is a prospective observational multicenter study establishing two cohorts: 1) athletes diagnosed positive for COVID-19 (cohort 1) and 2) federal squad athletes who perform their annual sports medical preparticipation screening (cohort 2). Comprehensive diagnostics including physical examination, laboratory blood analyses and blood biobanking, resting and exercise electrocardiogram (ECG), echocardiography, spirometry and exercise testing added by questionnaires are conducted at baseline and follow-up. Results and Conclusion: We expect that the results obtained, will allow us to formulate recommendations regarding RTP on a more evidence-based level.

Effects of face masks on performance and cardiorespiratory response in well-trained athletes.

BACKGROUND: During the COVID-19 pandemic, compulsory masks became an integral part of outdoor sports such as jogging in crowded areas (e.g. city parks) as well as indoor sports in gyms and sports centers. This study, therefore, aimed to investigate the effects of medical face masks on performance and cardiorespiratory parameters in athletes. METHODS: In a randomized, cross-over design, 16 well-trained athletes (age 27 ± 7 years, peak oxygen consumption 56.2 ± 5.6 ml kg-1 min-1, maximum performance 5.1 ± 0.5 Watt kg-1) underwent three stepwise incremental exercise tests to exhaustion without mask (NM), with surgical mask (SM) and FFP2 mask (FFP2). Cardiorespiratory and metabolic responses were monitored by spiroergometry and blood lactate (BLa) testing throughout the tests. RESULTS: There was a large effect of masks on performance with a significant reduction of maximum performance with SM (355 ± 41 Watt) and FFP2 (364 ± 43 Watt) compared to NM (377 ± 40 Watt), respectively (p < 0.001; ηp2 = 0.50). A large interaction effect with a reduction of both oxygen consumption (p < 0.001; ηp2 = 0.34) and minute ventilation (p < 0.001; ηp2 = 0.39) was observed. At the termination of the test with SM 11 of 16 subjects reported acute dyspnea from the suction of the wet and deformed mask. No difference in performance was observed at the individual anaerobic threshold (p = 0.90). CONCLUSION: Both SM and to a lesser extent FFP2 were associated with reduced maximum performance, minute ventilation, and oxygen consumption. For strenuous anaerobic exercise, an FFP2 mask may be preferred over an SM.

Perceived Fatigability: Utility of a Three-Dimensional Dynamical Systems Framework to Better Understand the Psychophysiological Regulation of Goal-Directed Exercise Behaviour.

A three-dimensional framework of perceived fatigability emphasises the need to differentiate between the qualitatively distinct inputs of sensory-discriminatory, affective-motivational and cognitive-evaluative processes that shape the perceptual milieu during prolonged endurance exercise. This article reviews the framework's utility to better understand how cause-effect relationships come to be and how perception-action coupling underpins pacing behaviour and performance fatigability. Preliminary evidence supports the hypotheses that perceived strain plays a primary role in trajectory regulation of pacing behaviour, core affect plays a primary and mediatory role in behavioural performance regulation, and the mindset shift associated with an action crisis plays a primary role in the intensity dependent volitional self-regulatory control of conflicting motivational drives. The constructs hypothesised to underpin perceived fatigability are systematically linked, context-dependent, constraint-based, distinguishable and show proportional continuous interdependency. They are further interrelated with dynamic changes in pacing behaviour, performance fatigability and physiological disturbance. Appropriate measurement selections for the subordinate constructs perceived physical strain, perceived mental strain, valence, arousal, action crisis and flow state are discussed. To better understand the non-proportional discontinuous effects of fatigue on discrete shifts in thought states and mindsets, non-linear dynamical systems theory is introduced as an unbiased overarching theory of governing principles in the temporal evolution of complex systems. This provides the opportunity to discuss the bio-psycho-social fatigue phenomenon from a dynamical and holistic perspective. The proposed framework offers a sophisticated alternative to the Gestalt concept of perceived exertion and comprehensively accounts for the psychophysiological processes that determine pacing behaviour and performance. It has the potential to enrich theory development and facilitate a deeper understanding of the psychophysiological regulation of goal-directed exercise behaviour.

Modelling perception-action coupling in the phenomenological experience of "hitting the wall" during long-distance running with exercise induced muscle damage in highly trained runners.

BACKGROUND: "Hitting the wall" (HTW) can be understood as a psychophysiological stress process characterised by (A) discrete and poignant onset, (B) dynamic interplay between physiological, affective, motivational, cognitive, and behavioural systems, and (C) unintended alteration of pace and performance. A preceding companion article investigated the psychophysiological responses to 20-km self-paced treadmill time trials after producing exercise-induced muscle damage (EIMD) via a standardised muscle-lengthening contraction protocol. METHODS: A 5-step procedure was applied determining the extent to which the observed data fit the hypothesised cause-effect relationships. Running with EIMD negatively impacts performance fatigability via (A) amplified physiological responses and a non-adaptive distress response and (B) deterioration in perceived fatigability: increase in perceived physical strain precedes decrease in valence, which in turn precedes increase in action crisis, eventually dissolving the initially aspired performance goal. RESULTS: First, haematological indicators of EIMD predicted increased blood cortisol concentration, which in turn predicted increased performance fatigability. Second, perceived physical strain explained 44% of the relationship between haematological indicators of EIMD and valence, which in turn predicted increased action crisis, which in turn predicted increased performance fatigability. The observed data fitted the hypothesised dual-pathway model well with good model-fit indices throughout. CONCLUSIONS: The hypothesised interrelationships between physiological strain, perception, and heuristic and deliberative decision-making processes in self-regulated and goal-directed exercise behaviour were applied, tested, and confirmed: amplified physiological strain and non-adaptive distress response as well as strain-perception-thinking-action coupling impact performance fatigability. The findings provide novel insights into the psychophysiological processes that underpin the phenomenological experience of HTW and alteration in pacing behaviour and performance.

The Psychophysiological Regulation of Pacing Behaviour and Performance Fatigability During Long-Distance Running with Locomotor Muscle Fatigue and Exercise-Induced Muscle Damage in Highly Trained Runners.

BACKGROUND: Locomotor muscle fatigue (LMMF) and exercise-induced muscle damage (EIMD) are common conditions experienced during long-distance running due to the pooled effect of mechanical and metabolic strain on the locomotor muscles. However, little is known about the instant effects of combined LMMF and EIMD on pacing behaviour and performance during the decisive final stages of 'real-world' long-distance running events. METHODS: Twenty-two highly trained runners (11 females) completed two maximal self-paced 20-km treadmill time trials in a counterbalanced crossover design: (A) in a tapered condition and (B) with LMMF and EIMD. Indicators of muscle damage, muscle metabolic strain, and endocrinological stress were assessed to investigate the physiological effects, and a three-dimensional framework of perceived fatigability was applied to investigate the perceptual effects of running with LMMF and EIMD on performance fatigability. RESULTS: LMMF and EIMD caused restrictions in work capacity and medium increases in blood leucocyte and neutrophil count, interleukin-6, and cortisol concentrations, collectively constituting a physiological milieu likely not conducive to high performance. LMMF and EIMD further caused large increases in perceived physical strain and large decreases in valence as well as large increases and decreases in action crisis and flow state, respectively. CONCLUSIONS: Under the constraint of amplified physical duress, findings are suggestive of heuristic and rational antecedents in the goal disengagement process. Dynamic changes in physiological and perceptual effects of LMMF and EIMD are hypothesised to underpin the observed alterations in pacing behaviour and performance fatigability during long-distance running. The applied three-dimensional framework provides a more comprehensive understanding of strain-perception-thinking-action coupling in centrally regulated and goal-directed exercise behaviour.

The Psychophysiological Determinants of Pacing Behaviour and Performance During Prolonged Endurance Exercise: A Performance Level and Competition Outcome Comparison.

INTRODUCTION: A three-dimensional framework of centrally regulated and goal-directed exercise behaviour emphasised the integration of distinct sensory-discriminatory, affective-motivational and cognitive-evaluative dimensions that underpin perceived fatigability. This study aimed to capture the complex interdependencies and temporal dynamics in these processes, their interrelations with observed pacing behaviour, performance and biochemical variables as well as their performance level- and competition outcome-dependent variances. METHODS: Twenty-three cyclists of distinct performance level categories engaged in individual and head-to-head competition time trials against a performance-matched opponent. Sensory, affective and cognitive processes were respectively assessed with the constructs perceived physical strain and perceived mental strain, valence and felt arousal underpinning core affect and action crisis characterised by a shift from an implemental to a deliberative mindset. RESULTS: Performance level- and competition outcome-dependent variances and differential temporal dynamics in constructs were associated with alterations in pacing behaviour, performance and physiological disturbance. Perceived physical and mental strain were primarily associated with observed pacing behaviour as necessary to align planned behaviour with current physiological state. Valence and arousal were primarily associated with differential responses in performance regulation. The mindset shift associated with an action crisis was primarily associated with non-adaptive, psycho-neuro-endocrinological distress response. CONCLUSION: The proposed constructs are interdependent in a nonlinear dynamic fashion, context dependent, constraint based, distinguishable by well-trained cyclists and interrelated with observed pacing behaviour, performance and physiological disturbance. The proposed framework provides a more comprehensive alternative to the Gestalt concept of perceived exertion and more completely accounts for centrally regulated and goal-directed exercise behaviour.

Towards a three-dimensional framework of centrally regulated and goal-directed exercise behaviour: a narrative review.

The Central Governor Model (CGM) ignited a paradigm shift from concepts of catastrophic failure towards central regulation of exercise performance. However, the CGM has focused on the central integration of afferent feedback in homeostatic control. Accordingly, it neglected the important role of volitional self-regulatory control and the integration of affective components inherently attached to all physiological cues. Another limitation is the large reliance on the Gestalt phenomenon of perceived exertion. Thus, progress towards a comprehensive multidimensional model of perceived fatigability and exercise regulation is needed. Drawing on Gate Control Theory of pain, we propose a three-dimensional framework of centrally regulated and goal-directed exercise behaviour, which differentiates between sensory, affective and cognitive processes shaping the perceptual milieu during exercise. We propose that: (A) perceived mental strain and perceived physical strain are primary determinants of pacing behaviour reflecting sensory-discriminatory processes necessary to align planned behaviour with current physiological state, (B) core affect plays a primary and mediatory role in exercise and performance regulation, and its underlying two dimensions hedonicity and arousal reflect affective-motivational processes triggering approach and avoidance behaviour, and (C) the mindset-shift associated with an action crisis plays a primary role in volitional self-regulatory control reflecting cognitive-evaluative processes between further goal-pursuit and goal-disengagement. The proposed framework has the potential to enrich theory development in centrally regulated and goal-directed exercise behaviour by emphasising the multidimensional dynamic processes underpinning perceived fatigability and provides a practical outline for investigating the complex interplay between the psychophysiological determinants of pacing and performance during prolonged endurance exercise.

Modelling the process of falling behind and its psychophysiological consequences.

INTRODUCTION: A preceding article investigated the psychophysiological responses to falling behind a performance matched opponent. The following temporally linked cause-effect relationships were hypothesised: falling behind precedes deterioration in valence, deterioration in valence precedes development of an action crisis, experience of an action crisis precedes psychoneuroendocrinological distress response and non-adaptive distress response reduces conduciveness to high performance, thereby preceding performance decrement. METHODS: In this article, we applied structural equation modelling to test the extent to which the observed data fit the hypothesised cause-effect relationships. A five-step procedure was applied to model the interrelationships between the major study variables in the hypothesised temporal order. RESULTS: Significant linear relationships were found between all hypothesised predictor and outcome variable pairs (p<0.024). The dynamic change in valence was a significant mediator (p=0.011) as it explained 35% of the relationship between falling behind and action crisis. All hypothesised cause-effect relationships continued to be significant after controlling for performance, descriptor, training and perceived strain variables. The observed data fitted the hypothesised structural model well with excellent model fit indices throughout. CONCLUSION: We applied, tested and confirmed the hypothesised debilitative psychophysiological processes that unfold in response to falling behind a performance matched opponent. The main findings were: deterioration in valence mediated the relationship between falling behind and action crisis, the mindset shift associated with an action crisis predicted increased blood cortisol concentrations and non-adaptive blood cortisol concentrations predicted performance decrement. The findings point towards the crucial role of affective and cognitive modifiers in centrally regulated and goal-directed exercise behaviour.