1
|
Miller PE, Gajjar P, Mitchell GF, Khan SS, Vasan RS, Larson MG, Lewis GD, Shah RV, Nayor M. Clusters of multidimensional exercise response patterns and estimated heart failure risk in the Framingham Heart Study. ESC Heart Fail 2024. [PMID: 38943268 DOI: 10.1002/ehf2.14797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 02/28/2024] [Accepted: 03/21/2024] [Indexed: 07/01/2024] Open
Abstract
AIMS New tools are needed to identify heart failure (HF) risk earlier in its course. We evaluated the association of multidimensional cardiopulmonary exercise testing (CPET) phenotypes with subclinical risk markers and predicted long-term HF risk in a large community-based cohort. METHODS AND RESULTS We studied 2532 Framingham Heart Study participants [age 53 ± 9 years, 52% women, body mass index (BMI) 28.0 ± 5.3 kg/m2, peak oxygen uptake (VO2) 21.1 ± 5.9 kg/m2 in women, 26.4 ± 6.7 kg/m2 in men] who underwent maximum effort CPET and were not taking atrioventricular nodal blocking agents. Higher peak VO2 was associated with a lower estimated HF risk score (Spearman correlation r: -0.60 in men and -0.55 in women, P < 0.0001), with an observed overlap of estimated risk across peak VO2 categories. Hierarchical clustering of 26 separate CPET phenotypes (values residualized on age, sex, and BMI to provide uniformity across these variables) identified three clusters with distinct exercise physiologies: Cluster 1-impaired oxygen kinetics; Cluster 2-impaired vascular; and Cluster 3-favourable exercise response. These clusters were similar in age, sex distribution, and BMI but displayed distinct associations with relevant subclinical phenotypes [Cluster 1-higher subcutaneous and visceral fat and lower pulmonary function; Cluster 2-higher carotid-femoral pulse wave velocity (CFPWV); and Cluster 3-lower CFPWV, C-reactive protein, fat volumes, and higher lung function; all false discovery rate < 5%]. Cluster membership provided incremental variance explained (adjusted R2 increment of 0.10 in women and men, P < 0.0001 for both) when compared with peak VO2 alone in association with predicted HF risk. CONCLUSIONS Integrated CPET response patterns identify physiologically relevant profiles with distinct associations to subclinical phenotypes that are largely independent of standard risk factor-based assessment, which may suggest alternate pathways for prevention.
Collapse
Affiliation(s)
- Patricia E Miller
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Priya Gajjar
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | | | - Sadiya S Khan
- Division of Cardiology, Department of Medicine and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ramachandran S Vasan
- Boston University's and NHLBI's Framingham Heart Study, Framingham, MA, USA
- University of Texas School of Public Health San Antonio, San Antonio, TX, USA
- Department of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
- Department of Population Health Sciences, University of Texas Health Science Center, San Antonio, TX, USA
| | - Martin G Larson
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
- Boston University's and NHLBI's Framingham Heart Study, Framingham, MA, USA
| | - Gregory D Lewis
- Division of Cardiology, Cardiovascular Research Center, and Pulmonary Critical Care Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ravi V Shah
- Division of Cardiology, Vanderbilt Translational and Clinical Research Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew Nayor
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- Boston University's and NHLBI's Framingham Heart Study, Framingham, MA, USA
- Section of Preventive Medicine and Epidemiology, Department of Medicine, Boston University School of Medicine, 72 E Concord Street, Suite L-516, Boston, MA, 02118, USA
| |
Collapse
|
2
|
Relation of Exercise Capacity to Incident Heart Failure Among Men and Women With Coronary Heart Disease (from the Henry Ford Exercise Testing [FIT] Project). Am J Cardiol 2022; 181:66-70. [PMID: 35970629 DOI: 10.1016/j.amjcard.2022.07.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/27/2022] [Accepted: 07/05/2022] [Indexed: 11/23/2022]
Abstract
Exercise capacity (EC) is inversely related to the risk of cardiovascular disease and incident heart failure (HF) in healthy subjects. However, there are no present studies that exclusively evaluate EC and the risk of incident HF in patients with known coronary heart disease (CHD). We aimed to determine the relation between EC and incident HF in patients with an established clinical diagnosis of CHD. We retrospectively identified 8,387 patients (age 61 ± 12 years; 30% women; 33% non-White) with a history of myocardial infarction (MI) or coronary revascularization procedure and no history of HF at the time of a clinically indicated exercise stress test completed between 1991 and 2009. EC was quantified in metabolic equivalents of task (METs) estimated from treadmill testing. Incident HF was identified through June 2010 from administrative databases based on ≥3 encounters with International Classification of Diseases, Ninth Revision 428.x. Cox regression analysis was used to evaluate the risk of incident HF associated with METs. Covariates included age; gender; race; hypertension, diabetes, hyperlipidemia, smoking, and MI; medications for CHD and lung diseases; and clinical indication for treadmill testing. During a median follow-up of 8.2 years (interquartile range 4.7 to 12.4 years) after the exercise test, 23% of the cohort experienced a new HF diagnosis. Lower EC categories were associated with higher HF incidence compared with METs ≥12, with nearly fourfold greater adjusted risk among patients with METs <6. Per unit increase in METs of EC was associated with a 12% lower adjusted risk for HF. There was no significant interaction based on race (p = 0.06), gender (p = 0.88), age ≤61 years (p = 0.60), history of MI (p = 0.31), or diabetes (p = 0.38). This study reveals that among men and women with CHD and no history of HF, EC is independently and inversely related to the risk of future HF.
Collapse
|
3
|
Rao P, Belanger MJ, Robbins JM. Exercise, Physical Activity, and Cardiometabolic Health: Insights into the Prevention and Treatment of Cardiometabolic Diseases. Cardiol Rev 2022; 30:167-178. [PMID: 34560712 PMCID: PMC8920940 DOI: 10.1097/crd.0000000000000416] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Physical activity (PA) and exercise are widely recognized as essential components of primary and secondary cardiovascular disease (CVD) prevention efforts and are emphasized in the health promotion guidelines of numerous professional societies and committees. The protean benefits of PA and exercise extend across the spectrum of CVD, and include the improvement and reduction of risk factors and events for atherosclerotic CVD (ASCVD), cardiometabolic disease, heart failure, and atrial fibrillation (AF), respectively. Here, we highlight recent insights into the salutary effects of PA and exercise on the primary and secondary prevention of ASCVD, including their beneficial effects on both traditional and nontraditional risk mediators; exercise "prescriptions" for ASCVD; the role of PA regular exercise in the prevention and treatment of heart failure; and the relationships between, PA, exercise, and AF. While our understanding of the relationship between exercise and CVD has evolved considerably, several key questions remain including the association between extreme volumes of exercise and subclinical ASCVD and its risk; high-intensity exercise and resistance (strength) training as complementary modalities to continuous aerobic exercise; and dose- and intensity-dependent associations between exercise and AF. Recent advances in molecular profiling technologies (ie, genomics, transcriptomics, proteomics, and metabolomics) have begun to shed light on interindividual variation in cardiometabolic responses to PA and exercise and may provide new opportunities for clinical prediction in addition to mechanistic insights.
Collapse
Affiliation(s)
- Prashant Rao
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Cardiovascular Research Center, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Jeremy M. Robbins
- Cardiovascular Research Center, Beth Israel Deaconess Medical Center, Boston, MA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| |
Collapse
|
4
|
Impact of concurrent training versus aerobic or resistance training on cardiorespiratory fitness and muscular strength in middle-aged to older adults: A systematic review and meta-analysis. Physiol Behav 2022; 254:113888. [PMID: 35728627 DOI: 10.1016/j.physbeh.2022.113888] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/16/2022] [Accepted: 06/17/2022] [Indexed: 12/29/2022]
Abstract
The effects of aerobic training (AT) on cardiorespiratory fitness (CRF), and resistance training (RT) on muscular strength, are well known in older adults. However, less is known about the potential additive benefits of concurrent training (CT) versus AT or RT alone in this population. We conducted a systematic review and meta-analysis to investigate the effects of CT, versus AT or RT, on CRF and muscular strength in middle-aged to older adults. PubMed and Web of Science were searched through October 2021 to identify randomized trials evaluating CT versus AT and/or RT in middle-aged and older adults (>50 yrs). Studies were included that measured CRF, using maximal or peak oxygen uptake (VO2max/peak); and/or lower- and upper-body muscular strength measured using 1-repetition maximum (1RM) to 10RM tests during isoinertial contractions, or peak torque during isometric dynamometry or isokinetic dynamometry at 30 to 60°/s. Standardized mean differences (SMD) and 95% confidence intervals (95% CIs) were determined using random or fixed effects models. Forty-nine studies involving 2,587 middle-aged to older participants with mean ages ranging from 55 to 88 years, were included in the meta-analysis. Results indicated that CT effectively increased VO2max/peak (SMD: 0.77, p = 0.005, 12 intervention arms) when compared to RT. In addition, CT effectively increased lower- (SMD: 0.60, p = 0.001, 43 intervention arms) and upper-body (SMD: 0.57, p = 0.001, 28 intervention arms) muscular strength when compared to AT. However, there were no differences in VO2max/peak (SMD: 0.09, p = 0.09, 33 intervention arms) between CT and AT, or in lower-body (SMD: 0.07, p = 0.48, 21 intervention arms) and upper-body (SMD: -0.07, p = 0.38, 17 intervention arms) muscular strength between CT and RT. Overall, CT was shown to be effective for increasing CRF and muscular strength in middle-aged to older adults and there was no negative effect on the magnitude of changes in these outcomes compared to either AT or RT alone. These results suggested that CT should be considered a viable strategy to improvement of CRF and muscular strength with aging.
Collapse
|
5
|
Qiu S, Cai X, Jia L, Sun Z, Wu T, Wendt J, Steinacker JM, Schumann U. Does objectively measured light-intensity physical activity reduce the risk of cardiovascular mortality? A meta-analysis. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 7:496-504. [PMID: 32514573 DOI: 10.1093/ehjqcco/qcaa051] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/28/2020] [Accepted: 06/02/2020] [Indexed: 12/13/2022]
Abstract
AIMS Current physical activity guidelines emphasize little on light-intensity physical activity (LPA) in terms of reducing the risk of cardiovascular mortality. This meta-analysis aimed to bridge this gap by assessing their association using objectively measured LPA data. METHODS AND RESULTS Databases of PubMed and Scopus were searched to April 2020 for prospective cohort studies that reported the association of LPA assessed by activity monitors with the risk of cardiovascular mortality in the general population. Multivariable-adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Dose-response and subgroup analyses were also performed. Six cohort studies with seven datasets enrolling 13 960 participants were included. LPA was all measured by accelerometers. The HR of LPA per 30 min/day for cardiovascular mortality was pooled to be 0.80 (95% CI 0.67-0.96). This association was non-linearly shaped (Pnonlinearity < 0.01) and unaffected by sex difference. Moreover, substituting LPA for sedentary time of 30 min/day lowered the risk of cardiovascular mortality by 16% (95% CI 0.73-0.96). Results showed further that LPA was inferior to moderate-to-vigorous physical activity in reducing the risk of cardiovascular mortality when performed with an equal time-length set at 30 min/day (HR 0.83 vs. 0.54, Pcomparison = 0.046), but became comparable if at an equal activity-amount set at 150 metabolic equivalents-min/day (HR 0.67 vs. 0.54, Pcomparison = 0.41). CONCLUSION LPA shows potential in reducing the risk of cardiovascular mortality, and interventions targeting at LPA improvement are worth being encouraged.
Collapse
Affiliation(s)
- Shanhu Qiu
- Department of Endocrinology, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Dongmen North Road No. 1017, Shenzhen 518020, China
| | - Xue Cai
- School of Nursing, Peking University, Xueyuan Road No.38, Beijing 100191, China
| | - Lijing Jia
- Department of Endocrinology, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Dongmen North Road No. 1017, Shenzhen 518020, China
| | - Zilin Sun
- Department of Endocrinology, Zhongda Hospital, Institute of Diabetes, School of Medicine, Southeast University, Dingjiaqiao No. 87, Nanjing 210009, China
| | - Tongzhi Wu
- Department of Endocrinology, Zhongda Hospital, Institute of Diabetes, School of Medicine, Southeast University, Dingjiaqiao No. 87, Nanjing 210009, China.,Adelaide Medical School and Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Level 5 Adelaide Health & Medical Sciences Building, Adelaide 5005, Australia
| | - Janine Wendt
- Division of Sports and Rehabilitation Medicine, Ulm University Medical Center, Leimgrubenweg 14, Ulm 89075, Germany
| | - Jürgen Michael Steinacker
- Division of Sports and Rehabilitation Medicine, Ulm University Medical Center, Leimgrubenweg 14, Ulm 89075, Germany
| | - Uwe Schumann
- Division of Sports and Rehabilitation Medicine, Ulm University Medical Center, Leimgrubenweg 14, Ulm 89075, Germany
| |
Collapse
|
6
|
Qiu S, Cai X, Sun Z, Wu T, Schumann U. Is estimated cardiorespiratory fitness an effective predictor for cardiovascular and all-cause mortality? A meta-analysis. Atherosclerosis 2021; 330:22-28. [PMID: 34225102 DOI: 10.1016/j.atherosclerosis.2021.06.904] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/17/2021] [Accepted: 06/23/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIMS Estimated cardiorespiratory fitness (eCRF) derived from algorithm correlates well with exercise testing-measured CRF, yet its clinical use for mortality risk stratification has not been systematically evaluated. This meta-analysis with dose-response analysis was conducted to quantify its association with risk of cardiovascular and all-cause mortality. METHODS Electronic databases were searched for prospective cohort studies that investigated the association of eCRF with risk of cardiovascular and all-cause mortality. Study-specific multivariate-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) per 1-metabolic equivalent (MET) higher of eCRF were pooled using a random-effects model. RESULTS Twenty-five datasets from 8 cohort studies that enrolled more than 170,000 participants were included. The summary HR per 1-MET higher of eCRF was 0.83 (95% CI 0.80 to 0.86) for cardiovascular mortality (11 datasets) and 0.83 (95% CI 0.78 to 0.88) for all-cause mortality (14 datasets) in the general population. These associations showed no sex-difference and were all linearly shaped (all pnonlinearity ≥ 0.27). The performance of eCRF (assessed by the area under the curve) in discriminating future risk of cardiovascular and all-cause mortality was higher than all its components (such as physical activity, resting heart rate, and body mass index, all p < 0.05), but slightly lower than exercise testing-measured CRF. CONCLUSIONS Higher eCRF was independently associated with lower risk of cardiovascular and all-cause mortality in the general population, indicating that eCRF might hold the potential as an effective and practical risk prediction tool in epidemiological or population research.
Collapse
Affiliation(s)
- Shanhu Qiu
- Institute of Diabetes, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China; Department of Endocrinology, Shenzhen People's Hospital (The Second Clinical Medical College of Jinan University; The First Affiliated Hospital of Southern University of Science and Technology), Shenzhen, China
| | - Xue Cai
- Institute of Diabetes, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Zilin Sun
- Institute of Diabetes, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China; Department of Endocrinology, Zhongda Hospital, Southeast University, Nanjing, China.
| | - Tongzhi Wu
- Adelaide Medical School and Centre of Research Excellence (CRE) in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | | |
Collapse
|
7
|
A proprotein convertase subtilisin/kexin type 9 inhibitor provides comparable efficacy with lower detriment than statins on mitochondria of oxidative muscle of obese estrogen-deprived rats. ACTA ACUST UNITED AC 2020; 27:1155-1166. [PMID: 32576799 DOI: 10.1097/gme.0000000000001586] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The aim of the study was to compare the effects of atorvastatin, a proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i), and 17β-estradiol on oxidative muscle mitochondria in a model of menopause with obesity. METHODS Female Wistar rats consumed either a standard diet (n = 12) or a high-fat/calorie diet (HFCD: n = 60). At week 13, standard diet-fed rats underwent a sham operation, whereas HFCD-fed rats underwent either a sham operation (n = 12) or an ovariectomy (n = 48). At week 19, all sham-operated rats received vehicle, and ovariectomized HFCD-fed rats received either vehicle, 40 mg/kg/d of atorvastatin, 4 mg/kg/d of PCSK9i (SBC-115076), or 50 μg/kg/d of 17β-estradiol for 3 weeks (n = 12/group). Metabolic parameters and soleus muscle physiology were investigated at the end of week 21. RESULTS Sham-operated and ovariectomized HFCD-fed rats developed obesity, hyperlipidemia, and insulin resistance, also showing increased oxidative phosphorylation (OXPHOS) proteins, ratio of p-Drp1-to-total Drp1 protein, malondialdehyde level, mitochondrial reactive oxygen species, and mitochondrial membrane depolarization in soleus muscle. All drugs equally decreased insulin resistance, OXPHOS proteins, ratio of p-Drp1-to-total Drp1 protein, and malondialdehyde level in soleus muscle. Only atorvastatin and PCSK9i attenuated hypertriglyceridemia, whereas 17β-estradiol had greater efficacy in preventing weight gain than the other two drugs. In addition, 17β-estradiol decreased mitochondrial reactive oxygen species and mitochondrial membrane depolarization. Atorvastatin increased ratio of cleaved caspase 3,8-to-procaspase 3,8, and cytochrome C. CONCLUSIONS 17β-Estradiol exhibits the greatest efficacy on the attenuation of obesity with the least harmful effect on skeletal muscle in a model of menopause with obesity, yet its effect on the treatment of hyperlipidemia is inferior to those of standard lipid-lowering agents.
Collapse
|
8
|
Qiu S, Cai X, Wu T, Sun Z, Guo H, Kirsten J, Wendt J, Steinacker JM, Schumann U. Objectively-Measured Light-Intensity Physical Activity and Risk of Cancer Mortality: A Meta-analysis of Prospective Cohort Studies. Cancer Epidemiol Biomarkers Prev 2020; 29:1067-1073. [PMID: 32303534 DOI: 10.1158/1055-9965.epi-19-1446] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/28/2020] [Accepted: 03/03/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The impact of light-intensity physical activity (LPA) in preventing cancer mortality has been questioned. To address this concern, the present meta-analysis aimed to quantify the association between objectively-measured LPA and risk of cancer mortality. METHODS We conducted a systematic literature search in PubMed and Scopus to January 2020. Prospective cohort studies reporting the association between objectively-measured LPA using activity monitors (e.g., accelerometers) and risk of cancer mortality in the general population were included. The summary hazard ratios (HR) per 30 min/day of LPA and 95% confidence intervals (CI) were obtained using a random-effects model. Dose-response analysis was used to plot their relationship. RESULTS Five prospective cohort studies were included, in which the definition of LPA based on accelerometer readings was mainly set within 100 to 2,100 counts/min. The summary HR for cancer mortality per 30 min/day of LPA was 0.86 (95% CI, 0.79-0.95; I 2 < 1%), and the association between LPA and risk reduction in cancer mortality was linearly shaped (P nonlinearity = 0.72). LPA exhibited a comparable magnitude of risk reduction in cancer mortality of moderate-to-vigorous physical activity regardless of equal time-length (0.87 per 30 min/day vs. 0.94 per 30 min/day, P interaction = 0.46) or equal amount (0.74 vs. 0.94 per 150 metabolic equivalents-min/day, P interaction = 0.11). Furthermore, replacing sedentary time by LPA of 30 min/day decreased the risk of cancer mortality by 9%. CONCLUSIONS Objectively-measured LPA conferred benefits in decreasing the risk of cancer mortality. IMPACT LPA should be considered in physical activity guidelines to decrease the risk of cancer mortality.
Collapse
Affiliation(s)
- Shanhu Qiu
- Department of Endocrinology, Zhongda Hospital, Institute of Diabetes, School of Medicine, Southeast University, Nanjing, China.,Division of Sports and Rehabilitation Medicine, Ulm University Medical Center, Ulm, Germany
| | - Xue Cai
- School of Nursing, Peking University, Beijing, China
| | - Tongzhi Wu
- Department of Endocrinology, Zhongda Hospital, Institute of Diabetes, School of Medicine, Southeast University, Nanjing, China.,Adelaide Medical School and Centre of Research Excellence (CRE) in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Zilin Sun
- Department of Endocrinology, Zhongda Hospital, Institute of Diabetes, School of Medicine, Southeast University, Nanjing, China.
| | - Haijian Guo
- Department of Integrated Services, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, China.
| | - Johannes Kirsten
- Division of Sports and Rehabilitation Medicine, Ulm University Medical Center, Ulm, Germany
| | - Janine Wendt
- Division of Sports and Rehabilitation Medicine, Ulm University Medical Center, Ulm, Germany
| | | | - Uwe Schumann
- Division of Sports and Rehabilitation Medicine, Ulm University Medical Center, Ulm, Germany
| |
Collapse
|