Stress Biomarkers, Mood States, and Sleep during a Major Competition: "Success" and "Failure" Athlete's Profile of High-Level Swimmers

Acute psychosocial stress modulates neural and behavioral substrates of cognitive control

Acute psychosocial stress affects learning, memory, and attention, but the evidence for the influence of stress on the neural processes supporting cognitive control remains mixed. We investigated how acute psychosocial stress influences performance and neural processing during the Go/NoGo task-an established cognitive control task. The experimental group underwent the Trier Social Stress Test (TSST) acute stress induction, whereas the control group completed personality questionnaires. Then, participants completed a functional magnetic resonance imaging (fMRI) Go/NoGo task, with self-report, blood pressure and salivary cortisol measurements of induced stress taken intermittently throughout the experimental session. The TSST was successful in eliciting a stress response, as indicated by significant Stress > Control between-group differences in subjective stress ratings and systolic blood pressure. We did not identify significant differences in cortisol levels, however. The stress induction also impacted subsequent Go/NoGo task performance, with participants who underwent the TSST making fewer commission errors on trials requiring the most inhibitory control (NoGo Green) relative to the control group, suggesting increased vigilance. Univariate analysis of fMRI task-evoked brain activity revealed no differences between stress and control groups for any region. However, using multivariate pattern analysis, stress and control groups were reliably differentiated by activation patterns contrasting the most demanding NoGo trials (i.e., NoGo Green trials) versus baseline in the medial intraparietal area (mIPA, affiliated with the dorsal attention network) and subregions of the cerebellum (affiliated with the default mode network). These results align with prior reports linking the mIPA and the cerebellum to visuomotor coordination, a function central to cognitive control processes underlying goal-directed behavior. This suggests that stressor-induced hypervigilance may produce a facilitative effect on response inhibition which is represented neurally by the activation patterns of cognitive control regions.

Effects of Official Chess Competition on Salivary Cortisol and Mood Swings in Adolescent Girls: A Win-Loss Approach

The current study examined the effects of official chess competition on salivary cortisol and mood swings in adolescent girls. Fourteen girl competitive chess players participated in the 5-day Swiss chess tournament held in nine heavy and light rounds. The tournament was performed at 9:00 a.m. (first, third, fifth, seventh, and ninth rounds) and 3:00 p.m. (second, fourth, sixth, and eighth rounds). Salivary cortisol and mood was measured before the tournament, before and after the second, fourth, sixth, and eighth rounds, and following the tournament (10 samples). The resting levels of salivary cortisol had considerably greater values on the first, second, third, and fourth competition days compared to 1 week before the competition (P = 0.001). The post-competition cortisol concentration was significantly higher on the second and third days than before the competition (P = 0.001). Winners had considerably higher levels of salivary cortisol compared to losers (P = 0.001). There was a significant increase in total mode disturbance (P = 0.001), anger (P = 0.009), and tension (P = 0.045) following heavy rounds (second and third day) compared to the values before the competition. At the same time, the Scores of vigor decreased significantly (P = 0.001). The findings of the present study showed participating in the official chess competition increased salivary cortisol and caused negative alterations in mood components associated with the difficulty and outcome of the match, indicating the psychological stress. Hence, psychological interventions can be used for psychological recovery of competitive chess players after the competition.

Influence of iron supplementation on fatigue, mood states and sweating profiles of healthy non-anemic athletes during a training exercise: A double-blind, randomized, placebo-controlled, parallel-group study

Iron is specifically important to athletes, and attention has grown to the association between sports performance and iron regulation in the daily diets of athletes. The study presents new insights into stress, mood states, fatigue, and sweating behavior among the non-anemic athletes with sweating exercise habits who consumed a routine low dose (3.6 mg/day) of iron supplementation. In this double-blind, randomized, placebo-controlled, parallel-group study, both non-anemic male (N = 51) and female (N = 42) athletes were supplemented either with a known highly bioavailable iron formulation (SunActive® Fe) or placebo during the follow-up training exercise period over four weeks at their respective designated clinical sites. The effect of oral iron consumption was examined on fatigue, stress profiles, as well as the quality of life using the profile of mood state (POMS) test or a visual analog scale (VAS) questionnaire, followed by an exercise and well-being related fatigue-sweat. Also, their monotonic association with stress biomarkers (salivary α-amylase, salivary cortisol, and salivary immunoglobulin A) were determined using spearman's rank correlation coefficient test. Repeated measure multivariate analysis of variance (group by time) revealed that the total mood disturbance (TMD) score was significantly lower (P = 0.016; F = 6.26) between placebo and iron supplementation groups over the four weeks study period among female athletes. Also, a significant reduction in tired feeling/exhaustion after the exercise (P = 0.05; F = 4.07) between the placebo and iron intake groups was noticed. A significant within-group reduction (P ≤ 0.05) was noticed in the degree of sweat among both male and female athletes after 2 and 4 weeks of iron supplementation, while athletes of the placebo intake group experienced a non-significant within-group reduction in the degree of sweat. Overall, the result indicates routine use of low dose (3.6 mg/day) iron supplementation is beneficial for non-anemic endurance athletes to improve stress, mood states, subjective fatigue, and sweating conditions.

Monitoring mood state to improve performance in soccer players: A brief review

Introduction

Psychological aspects of sport are key in maintaining athlete motivation and make a difference in competitive outcomes. Adjustments to training may be necessary according to athletes' emotional state. Therefore, it is important to assess and quantify mood states throughout the season in team sports, including among soccer players. The Profile of Mood States (POMS) is a widely used questionnaire that assesses emotional states characterized by positive or negative feelings and can be administered repeatedly to assess changes in mood state. This review aims to assess and summarize the current literature on mood state variation in soccer players with a specific focus on training loads, training modalities, and competitive performance.

Methods

A literature search was systematically conducted and resulted in 156 records. After removing duplicates, items with irrelevant titles and abstracts were screened out, and full texts were then screened for relevance and compared with inclusion and exclusion criteria. The remaining 37 articles were included in the final qualitative synthesis.

Results

POMS scores were related to variability in training load, intensity of the training period, modality of training exercises, competitive performance and time of day in soccer players. Common recommendations include monitoring the mood state of soccer players during training sessions, matches, and throughout training periods to detect early signs of psychological disturbance and aid in optimizing high-level training performance.

Conclusion

The POMS allows for monitoring of players' psychological state, providing coaches with data to aid in adjusting acute program variables according to players' psychological states and improve performance. Results offer practical support for the use of a simple POMS measurement as part of an overall program to monitor the players' psychological states. Results also highlight how training choices (i.e., load and exercise modality) and competitive performance are related to mood states (i.e., tension, anger, confusion, depression, fatigue, and vigor).

Effects of combined training during the COVID-19 pandemic on metabolic health and quality of life in sedentary workers: A randomized controlled study

This study aimed to analyze the effects of a combined training (CT) program performed during the first national lockdown due to the COVID-19 pandemic on body composition, metabolic profile, quality of life and stress in sedentary workers, and examines whether changes in the metabolic profile are associated with changes in health-related outcomes which are modifiable by exercise. We evaluated 31 sedentary workers (48.26 ± 7.89 years old). Participants were randomly assigned to a CT group (i.e., performed 16 weeks of exercise) or to a non-exercise control group. The CT program consisted of 16-week of resistance and aerobic exercise. Body composition, glycemic and lipidic profiles, cardiorespiratory fitness (CRF), health-related quality of life and stress levels were assessed pre- and post-intervention. After the intervention period, the CT group demonstrated significantly lower waist and hip circumference (p < 0.05) values than the control group. The control group significantly increased the fasting glucose and HOMA-IR after 16 weeks follow-up (+4.74 mg/dL, p = 0.029; and +0.41 units, p = 0.010, respectively), whiles no significant changes were observed in the CT group in the same parameters (+3.33 mg/dL, p = 0.176; and +0.04 units, p = 0.628, respectively). No changes were observed in the lipid profile for either group (p > 0.05). A significant positive relationship was detected between the change in BMI with the changes in insulin and HOMA-IR (r = 0.643, p = 0.024; and r = 0.605, p = 0.037, respectively). In addition, the changes in CRF were negatively associated with the changes in total cholesterol (r = -0.578, p = 0.049). We observed differences between groups on perceived stress levels and physical, psychological, and environmental domains of quality of life, with the CT group showing better results. Moreover, the CT group improved perceived life satisfaction (+3.17 points, p = 0.038). The findings of the present study suggest that the participants who remained physically active during the first pandemic-related lockdown were able to mitigate the deleterious effects associated with a sedentary lifestyle.

Salivary mental stress biomarkers in COVID-19 patients

BACKGROUND

During the COVID-19 pandemic, mental health disorders and level of stress show a major increase compared to before the pandemic. Coronavirus-related stress is recently the leading cause of negative impacts on global mental health. Thus, maintaining positive mental health is as important as maintaining physical health during COVID-19. The aim of this study was to analyze salivary mental stress biomarkers as cortisol, alpha-amylase, and chromogranin A in hospitalized patients with COVID-19 to compare their potential relationship with stress symptoms.

MATERIAL AND METHODS

A total of 80 adult hospitalized patients with moderate COVID-19 disease and a control group (n = 80) randomly selected were conducted as participants. Saliva cortisol (sCort), saliva alpha-amylase (sAA), and saliva and chromogranin A (sCgA) were determined by the ELISA method (Bio Vendor, USA). Symptoms of stress were measured with a stress symptom checklist (SSCL).

RESULTS

The patients group presented significantly higher levels of sCort, sAA, and sCgA compared with the control group. The correlation analysis showed a positive correlation with strong strength between sCort and sAA (r = 0.934, p < 0.01), as well as sAA with sCgA (r = 0.714, p < 0.01). A moderate positive correlation was found between sCort with sCgA (r = 0.618, p < 0.05). Based on their stress scores from the SSCL the patients were associated with high stress level (30.00%) and very high stress levels (67.5%). In terms of the controls, all the participants showed a low to moderate stress level. We found significant positive correlation between levels of stress and salivary biomarkers.

CONCLUSION

Data from our study demonstrated that salivary biomarkers are promising tools of exploring COVID-19 related stress.

Presleep Heart-Rate Variability Biofeedback Improves Mood and Sleep Quality in Chinese Winter Olympic Bobsleigh Athletes

PURPOSE

To evaluate the effectiveness of heart-rate variability (HRV) biofeedback in improving autonomic function, mood, and sleep in elite bobsleigh athletes.

METHODS

Eight Chinese Winter Olympic bobsleigh athletes (age: 24 [2] y, body mass: 89 [15] kg, and height: 184 [5] cm) completed a randomized crossover study with and without HRV biofeedback before a single night's sleep. HRV biofeedback was provided 35 minutes prior to bedtime in the experimental condition. The assessment of HRV took place 45 and 10 minutes before bedtime. The Profile of Mood States questionnaire was completed 50 and 15 minutes prior to bedtime. Sleep duration and quality were measured through an air-mattress sleep-monitoring system.

RESULTS

Sleep efficiency (P = .020; F = 7.831; CI, 0.008 to 0.072) and the percentage of deep sleep duration increased (P = .013; F = 10.875; CI, 0.006 to 0.035), while the percentage of light sleep decreased (P = .034; F = 6.893; CI, -0.038 to -0.002). Presleep HRV biofeedback increased parasympathetic and decreased sympathetic activity. Mood states of anger (P = .006, F = 7.573), panic (P = .031, F = 4.288), tension (P = .011, F = 6.284), depression (P = .010, F = 6.016), fatigue (P = .000, F = 16.901), and total mood disturbance (P = .001, F = 11.225) were reduced before sleep.

CONCLUSION

Presleep HRV biofeedback improved some measures of autonomic function, mood, and sleep quality in Chinese Olympic bobsleigh athletes. Presleep HRV biofeedback provides a practical strategy that may help reduce sleep disturbances during periods of training and competition.

Automated Stress Recognition Using Supervised Learning Classifiers by Interactive Virtual Reality Scenes

Virtual reality (VR) technology offers a great opportunity to explore stress disorder therapies. We created a VR stress training system, which incorporates three highly interactive stressful scenes to elicit stress, and demonstrate the concurrent variations between physiological data (heart rate, electrodermal activity and eye-blink rate) and self-reported stress ratings through a self-designed customized perceived stress questionnaire (SSAI) and wearable devices. Several supervised learning models were rigorously applied to automate stress recognition. Our findings include the evaluations of the VR system by computing Cronbach's alpha ( α = 0.72 ) and Kaiser-Meyer-Olkin (KMO) coefficient ( η = 0.78 ) through a retrospective survey, which were subsequently confirmed as reliable on four aspects (sense of presence, sense of space, sense of immersion and sense of reality) via factor analysis. Additionally, we demonstrate the effectiveness of physiology-based stress level classification (no stress, low stress and high stress) and continuous SSAI score prediction, with accuracy reaching 0.742 by bagging ensemble learning model and goodness-of-fit reaching 0.44 via multivariate stepwise regression. This study provides detailed insight regarding the effect of objective physiological measures on the validation of subjective self-ratings under a novel complex VR stress training system, which stimulates the further investigations of stress disorder recognition and treatment.

Prediction and Analysis of Tokyo Olympic Games Swimming Results: Impact of the COVID-19 Pandemic on Swimmers' Performance

Due to the COVID-19 pandemic in the 2019-2020 season, swimming competitions and training have been limited leading to a setback in performances. The study analyzed if, during the subsequent season, swimmers' have been able to regain the lost performance. Swimming time trends were analyzed comparing Tokyo with Rio Olympics and with mathematically predicted results. The gap between the gold medalist and the last finalist, and the differences between men and women have also been considered. Swimming competition results of females and males, in 100 m and 200 m Freestyle and Backstroke, were collected from the Olympics' official website. Results showed that at Tokyo Olympics almost all swimmers' times improved as compared to Rio's. Analysis of performance trends highlighted that performance progression does not proceed in a linear fashion and that is best predicted by more recent results. Women's progression was higher than men's and the gap between the first and last finalist constantly decreased, except for the Tokyo Olympics. In conclusion, the unprecedented Tokyo Olympic Games and qualification year seems not to have disrupted all Olympic swimmers' performance, suggesting that stakeholders support and athlete's coping ability might safeguard the subsistence of performance.

Effects of combined training on metabolic profile, lung function, stress and quality of life in sedentary adults: A study protocol for a randomized controlled trial

Background

Both physical inactivity and sedentary behavior are considered modifiable risk factors for chronic diseases and all-cause mortality. Adult office-workers spend most of their working day in sedentary behaviors, so they are particularly at high risk of developed chronic diseases (e.g., cardiovascular diseases, metabolic disorders like diabetes mellitus, …). It seems important to promote behavioral changes that could prevent or delay metabolic disease development. Evidence supports the use of exercise programs, however, to date there are several knowledge gaps and inconsistencies in the literature regarding the effects of Combined Training (i.e., aerobic plus resistance training) in sedentary healthy adults. This paper outlines an RCT designed to evaluate the effects of a 16-week combined training program on biochemical and immune markers of metabolic disease, lung function, salivary stress hormones and subjective quality of life (primary outcomes), as well as on body composition and physical fitness (secondary outcomes) in sedentary middle-aged office-workers. Furthermore, we aimed to assess the associations between the changes promoted by the exercise program and the different variables studied.

Methods and design

This is a single-blinded two-arm RCT with parallel groups. A minimum of healthy 40 office-workers aged 40–64 years will be recruited to engage in a 16-week intervention study. After baseline assessments, participants will be randomized to one of the two groups: (1) combined training group or (2) control group. Baseline assessments will be repeated after 8 weeks of intervention (mid-testing) and upon completion of the intervention (post-testing).

Discussion

This RCT involves a multi-disciplinary approach and seems to be a relevant contribution to understanding the potential role of combined training in improving the metabolic profile, lung function, stress, and quality of life in adults. The results can provide important insights for clinical recommendations and for the optimization of strategies to prevent metabolic disorders in adults with sedentary jobs.

Trial registration

This trial is registered with ClinicalTrials.gov (registration number: NCT04868240; date of registration April 30, 2021).

Selected Immunoendocrine Measures for Monitoring Responses to Training and Match Load in Professional Association Football: A Review of the Evidence

Biomarkers relating to player “stress balance,” immunological (ie, immunoglobulin-A), and hormonal (ie, testosterone and cortisol [T:C]) status are now commonly used in football. This article is our critical review of the scientific literature relating to the response of these measures to player load and their relationships with player health. The commonly reported relationship between immunoglobulin-A and training or match load highlights its sensitivity to changes in psychophysiological stress and the increased risk of compromised mucosal immunity. This is supported by its close relationship with symptoms of upper respiratory tract infection and its association with perceived fatigue in football players. Testosterone and cortisol concentrations and the testosterone–cortisol ratio are sensitive to changes in player load, but the direction of their response is often inconsistent and is likely influenced by player training status and non-sport-related stressors. Some evidence indicates that sustained periods of high training volume can increase resting testosterone and that sustained periods of low and high training intensity can increase resting cortisol, compromising the testosterone–cortisol ratio. These findings are noteworthy, as recent findings indicate interrelationships between testosterone, cortisol, and testosterone:cortisol and perceived measures of fatigue, sleep quality, and muscle soreness in football players. Variability in individual responses suggests the need for a multivariate and individualized approach to player monitoring. Overall, we consider that there is sufficient evidence to support the use of salivary immunoglobulin-A, testosterone, cortisol, and testosterone:cortisol measures as part of a multivariate, individualized player monitoring system in professional football.

The Effect of an Alternative Swimming Learning Program on Skills, Technique, Performance, and Salivary Cortisol Concentration at Primary School Ages Novice Swimmers

The playful training method shows positive effects on sports learning, thus the aim of the present study was to compare the effect of two different swimming learning programs. In an 8-week intervention with a training frequency of three times per week, 23 healthy primary school-aged novice swimmers (13 boys, 10 girls) aged 9.0 ± 0.9 participated. They were split into control (CG) and alternative (AG) groups and evaluated on skills (Start, Sink), backstroke (BK) and breaststroke (BR) technique, performance (Skills time, Kicks Time), and salivary cortisol concentration. According to the results, "Start" had a greater percentage of success in AG, at the first (CG = 9.1% vs. AG = 58.3%, p = 0.027) and third (CG = 63.6% vs. AG = 100%, p = 0.037) measurement. Additionally, greater scores were found in technique for AG in both BK (p = 0.009, η² = 0.283) and BR (p = 0.020, η² = 0.231). Salivary cortisol concentration was decreased for both groups (p < 0.001) and greater in CG at the second measurement (p < 0.001). The alternative swimming learning program was found to be more efficient or equally effective, compared with the standardized method in-water skills, swimming technique and performance, and in salivary cortisol concentration.

Differential responses of salivary cortisol, amylase, and chromogranin A to academic stress

Salivary biomarkers have been widely used to help diagnose stress, anxiety, and/or depression. This study aimed to compare the responses of three commonly investigated salivary stress biomarkers that represent the hypothalamic-pituitary-adrenal activity (cortisol; sCort) and the sympathetic activity (alpha-amylase; sAA and chromogranin A; sCgA), using academic oral presentation as a model of stress. Twenty postgraduate dental students attended the seminar class as presenter and audience. The presenters' performances were evaluated by the instructors suggesting more stress than the audience. The saliva was collected two times: before attending class and after an academic presentation (for presenters) or during the class (for audience). The pulse rates (PR) were also recorded. The results showed that the levels of all three biomarkers, as well as PR, were significantly higher in the presenter group compared with the audience group; however, the changes were most prominent with sCort and sAA (99.56 ± 12.76% for sCort, 93.48 ± 41.29% for sAA, 16.86 ± 6.42% for sCgA, and 15.06 ± 3.41% for PR). When compared between pre-post presentation, the levels of sCgA were not different, while those of sCort and sAA were significantly increased. These results suggest more sensitive reactivity to academic stress of sCort and sAA compared with sCgA and that the response of sCgA did not necessarily follow sAA pattern even though both are claimed to reflect the sympathetic activity. More studies are needed to elucidate the roles of sCgA in stress.

Summated training and match load predictors of salivary immunoglobulin-A, alpha-amylase, testosterone, cortisol and T:C profile changes in elite-level professional football players: A longitudinal analysis

We examined how summated training and match load measures relate to salivary immunological and hormonal profile changes in professional football players. Data were collected from 18 elite-level professional male football players from one English Championship team across a complete 40 wk competitive season. Daily training (micro-technology) and match (computerised tracking) measures of total, high-speed and high-metabolic load running distance and sprint, acceleration, deceleration and sRPE load were converted into exponentially weighted moving average "acute" (7d), "chronic" (28d) and acute:chronic composite load measures. Bi-weekly morning saliva samples were analysed for immunoglobulin-A, alpha-amylase, testosterone, cortisol and testosterone:cortisol. A two-stage data reduction technique using partial least squares modelling and a backward stepwise selection procedure determined the most parsimonious model for each salivary variable. Testosterone had non-linear relationships with chronic total (P = 0.015; Cohen's D: large), high-metabolic load (P = 0.001;small) and high-speed (P = 0.001;trivial) running distance and linear relationships with chronic sRPE (P = 0.002;moderate ↓) and acute:chronic high-speed running distance (P = 0.001; trivial ↑). Cortisol had a non-linear relationship with chronic high-speed running distance (P = 0.001;trivial). Testosterone:cortisol had non-linear relationships with chronic decelerations (P = 0.039;small) and chronic summated acceleration and deceleration load (P = 0.039;small). Non-linear relationships typically indicated optimal hormonal responses at squad mean loads. No load variables clearly related to salivary immunoglobulin-A or alpha-amylase changes. We conclude that chronic total and high-intensity load measures relate to hormonal changes and might be useful indicators of player readiness. Acute load variables were not related to immunological or hormonal changes and consequently, should not be used as surrogate measures of player readiness in isolation.

Effects of a Soccer Tournament on the Psychohormonal States of Collegiate Female Players

ABSTRACT

Broodryk, A, Pienaar, C, Edwards, D, and Sparks, M. Effects of a soccer tournament on the psychohormonal states of collegiate female players. J Strength Cond Res 35(7): 1873-1884, 2021-A gap exists in the literature concerning the connection between soccer players' hormonal and psychological responses when playing a tournament, or even a match, and its outcome (victory or defeat). This study evaluates the effects of a week-long tournament on the psychohormonal states of collegiate female soccer players. Eight players' cortisol (saliva sample), mood states (Incredibly Short Profile of Mood States [ISP]), and state-anxiety (state subscale of the State-Trait Anxiety Inventory) were assessed 1 hour before and 15 minutes after every game. Cortisol increased significantly after most matches, with intramatch differences observed (p < 0.05, d > 1.2). Match intensity influenced cortisol secretion, with greater secretion as intensity increased. The ISP demonstrated intramatch differences for the subscales' fatigue, depression, tension, and vigor (p < 0.05). Matches lost produced a higher total mood disturbance (TMD) index compared with matches won (p = 0.001, d = 1.4). Cortisol correlated with the TMD and various mood subscales before a winning outcome, with the ISP correlating at all times with the anxiety scores (p < 0.05). In conclusion, these results indicate that physiological and psychological variables combine to contribute to the stress response during a tournament. Focusing on high-intensity activities and minimizing fatigue are important, as both are associated with raised cortisol and negative mood states. Finally, implementing a mood questionnaire over a tournament can be beneficial, as sensitive information on players' hormonal and perceived anxiety states, which subsequently affect physical performance, can be obtained.

Prevalence of poor sleep quality in athletes before competition

OBJECTIVES

The purpose of this study was to investigate athletes sleep quality before competition and its relationship with age, gender, sport modality, competitive level, competition result, and practice time.

METHODS

The sample was 1010 Brazilian athletes (656 men and 354 women; 511 young and 499 adults), with an age of 20 ± 7 years old. Participants answered the question 'How would you evaluate the quality of your sleep in the past few days?' Participants rated their sleep quality on a Likert-type scale as follows: 1 = very poor, 2 = poor, 3 = regular, 4 = good, 5 = excellent.

RESULTS

Young athletes were 2.30 times more likely to experience poor sleep than adult athletes (p < 0.01; 95% Confidence Interval [CI] = 1.47-3.61). Individual athletes were 3.45 times more likely to present poor sleep compared to athletes of team sports (p = 0.00; 95% CI = 2.18-5.48). International athletes were 1.71 times more likely to present regular sleep compared to regional athletes (p = 0.01; 95% CI = 1.16-2.51). Conclusions: Thus, our study indicates that young, individual sports, and international athletes may be at higher risk of poor sleep quality before competitions.

Association Between Hormonal Status, Stress, Recovery, and Motivation of Paralympic Swimmers

Purpose: The present study aimed to investigate associations between hormonal profile (cortisol and testosterone) and the psychobiological aspects of Paralympic athletes during a competitive season. Method: Male Brazilian Paralympic swimmers (n = 11) were evaluated in three Training Camps (TC) during the cycle of training for the Paralympic Games RIO 2016. Questionnaires were used for data collection of stress and recovery, motivation in sport and hormonal status was assessed by salivary samples of cortisol ([Csal]) and testosterone ([Tsal]) concentrations. The Friedman test was used to identify overall significant differences at the three TC for each variable. When the overall p value indicated statistical significance (p < .05), a post hoc Wilcoxon signed-rank test for paired data was used to compare pairs of TC. The Spearman correlation was used to identify associations between the hormonal profile and the psychobiological aspects. Results: There was an association between the [Csal] and the "Conflicts/Pressure" sub-scale (r = 0.60; p = .04) in TC1 and the "Lack of Energy" subscale (r = 0.63; p = .03) in TC2. In the TC3, there were correlations between [Tsal] and "To Know" intrinsic motivation (r = 0.83, p < .01), "Objectives"(r = 0.66, p < .02), "Experiences" (r = 0.65, p < .02) and "Amotivation" (r = -0.70, p = .01). There were also associations between the [Tsal] and the "Social Recovery" (r = 0.77, p < .01), "General Wellness" (r = 0.73, p < .01), "Sleep Quality" (r = 0.63, p = .03) and "Self-efficacy" (r = 0.60, p = .05) subscales. In TC3, there was an association between [Tsal] and the "Success" (r = 0.61, p = .04), "Sleep Quality" (r = 0.62, p = .03), "Personal Accomplish" (r = 0.82, p < .01), "Self-efficacy" (r = 0.82, p < .05), "Self-regulation" (r = 0.85, p < .01) and "Physical Recovery" (r = 0.80, p < .01) subscales. The data demonstrate associations between biomarkers (salivary testosterone and cortisol) and psychobiological domains of Paralympic swimmers.

Motorcycling performance and sleepiness during an extended ride on a dynamic simulator: relationship with stress biomarkers

OBJECTIVE

Powered two-wheelers (PTW) make up a large proportion of fatal accidents. The aim of this study was to investigate the effects of time-of-day and total sleep deprivation (SD) on simulated motorcycling performance during extended riding sessions (60 min), while evaluating stress mechanisms.

APPROACH

A total of 16 healthy males participated in four simulated motorcycling sessions at 07:00, 11:00, 15:00 and 19:00, including city (8 min), country (2 min) and highway pathways (40 min), after a normal night of sleep and after total SD (30 h), in a randomized counterbalanced order. The recorded motorcycle parameters included: variation of lateral position, number of inappropriate line crossings (ILC), falls, riding errors, speed and speed limit violations. Subject parameters included the number of microsleeps in each pathway, the number of lapses during the 3-min psychomotor vigilance task (PVT-Brief version), and the Karolinska sleepiness scale (KSS) score. Saliva samples were used to assess cortisol (sC), α-amylase (sAA), and chromogranin-A (sCgA). ANOVAs and Pearson's correlation analysis were performed between these variables.

MAIN RESULTS

Most parameters were influenced by an interaction effect between 'Motorcycling pathways' × 'SD' (speed (p < 0.05), legal speed violations (p < 0.01), variation of lateral position (p < 0.001), falls (p < 0.001), EEG-microsleeps (p < 005)). An interaction effect between 'SD' × 'Time-of-day' influenced the number of ILCs (p < 0.01), sC (p < 0.05) and sCgA (p < 0.05) levels. SD affected KSS scores (p < 0.001) and PVT lapses (p < 0.05). The highest disturbances were associated with highway motorcycling simulation.

SIGNIFICANCE

Sleepiness due to circadian or SD and fatigue effects significantly affect riding and increase the risks involved with PTWs. The activation of both stress systems seems not sufficient to alleviate these deleterious effects.

Stress, Professional Lifestyle, and Telomere Biology in Elite Athletes: A Growing Trend in Psychophysiology of Sport

Professional lifestyle and championship period often put a great deal of pressure on athletes, who usually experience highly stressful periods during training for competitions. Recently, biomarkers of cellular aging, telomere length (TL) and telomerase activity (TA), have been considered to investigate the effects of stress and lifestyle factors. Studies in non-athletic populations have shown that stress and poor lifestyle decrease TL and TA. On the other hand, it has been shown that in general, exercise increases TL and its activity, although the underlying mechanisms remained largely unexplored. TL and TA outcomes in elite athletes remain inconclusive and mainly affected by confounding factors, such as age. Elite athletes, therefore, might offer a unique target group for studying exercise-telomere hypothesis for further investigation of the roles of stressors on telomere-related biomarkers. In this perspective, we highlight the potentials for studying these psychophysiological markers in elite athletes in order to understand stress-aging relationship and potential underlying mechanisms. Moreover, we present important methodological aspects that could help in the development of future experimental designs.

Sleep quality monitoring in individual sports athletes: parameters and definitions by systematic review

In the present review, we identify which instruments and parameters are used for sleep quality monitoring in individual sport athletes and which definitions were used for sleep quality parameters in this literature field. Systematic searches for articles reporting the qualitative markers related to sleep in team sport athletes were conducted in PubMed, Scopus and Web of Science online databases. The systematic review followed the Preferred Reporting Items for Systematic Reviews. The initial search returned 3316 articles. After the removal of duplicate articles, eligibility assessment, 75 studies were included in this systematic review. Our main findings were that the most widely used measurement instruments were Actigraphy (25%), Rating Likert Scales (16%) and Sleep Diary (13%). On sleep quality parameters (Sleep duration = 14%; Wake after sleep onset = 14%; Sleep Quality = 12%; Sleep Effciency = 11% and Sleep Latency = 9%), the main point is that there are different definitions for the same parameters in many cases reported in the literature. We conclude that the most widely used instruments for monitoring sleep quality were Actigraphy, Likert scales and Sleep diary. Moreover, the definitions of sleep parameters are inconsistent in the literature, hindering the understanding of the sleep-sport performance relationship.

The effect of time of day and chronotype on the relationships between mood state and performance in a Wingate test

The purpose of this study was to investigate the effects of time-of-day and morning vs. evening chronotype on the relationships between mood state and performance of extreme intensity cycling exercise. A quasi-experimental between-groups design was used to test the hypothesis that there would be an effect of time-of-day on mood state and physical performance, that mood state and physical performance would be interrelated, and that the relationships would be influenced by participants' morning vs. evening chronotype. From 74 university students who volunteered, 7 were identified as morning types (M-types) and 7 as evening types (E-types). They completed the Profile of Mood States (POMS) questionnaire and performed a 30 s Wingate test on three different days, once at 08h00, once at 14h00, and once at 20h00. The main performance measure, work done in the Wingate test, increased across the day (16.4 ± 4.8 kJ < 17.0 ± 5.0 kJ < 17.6 ± 5.2 kJ; p < .01). For the M-types, individual changes in performance from the morning to the afternoon were correlated with individual changes in the POMS score for vigor (r = 0.81; p = .03) and changes in performance from the afternoon to the evening were correlated with individual changes in fatigue (r = - 0.85, p = .02). For the E-types, the opposite was true, as morning-to-afternoon changes in performance were correlated with individual changes in fatigue (r = - 0.70, p = .08) and afternoon-to-evening changes in performance were correlated with individual changes in vigor (r = 0.78, p = .04). Results demonstrate a time-of-day effect on morning vs. evening chronotype-dependent relationships between mood state and cycling performance.

Changes in Markers of Oxidative Stress and α-Amylase in Saliva of Children Associated with a Tennis Competition

The purpose of this paper was to analyze the changes caused by a one-day tennis tournament in biomarkers of oxidative stress and α-amylase in saliva in children. The sample was 20 male active children with the following characteristics: (a) age of players = 9.46 ± 0.66 years; (b) weight = 34.8 ± 6.5 kg; (c) height = 136.0 ± 7.9 cm; (d) mean weekly training tennis = 2.9 ± 1.0 h. The tennis competition ran for one day, with four matches for each player. Data were taken from the average duration per match and the rating of perceived exertion (RPE). Four biomarkers of antioxidant status: uric acid (AU), Trolox equivalent antioxidant capacity (TEAC), ferric reducing ability of saliva (FRAS, cupric reducing antioxidant capacity (CUPRAC) and salivary alpha-amylase (sAA) as a biomarker of psychological stress were measured in saliva. The time points were baseline (at home before the tournament), pre-competition (immediately before the first match) and post-match (after each match) measurements. The four biomarkers of antioxidant status showed a similar dynamic with lower values at baseline and a progressive increase during the four matches. Overall one-day tennis competition in children showed a tendency to increase antioxidant biomarkers in saliva. In addition, there was an increase in pre-competition sAA possibly associated with psychological stress. Further studies about the possible physiological implications of these findings should be performed in the future.

The Interplay Between Plasma Hormonal Concentrations, Physical Fitness, Workload and Mood State Changes to Periods of Congested Match Play in Professional Soccer Players

Background

The regular assessment of hormonal and mood state parameters in professional soccer are proposed as good indicators during periods of intense training and/or competition to avoid overtraining.

Objective

The aim of this study was to analyze hormonal, psychological, workload and physical fitness parameters in elite soccer players in relation to changes in training and match exposure during a congested period of match play.

Methods

Sixteen elite soccer players from a team playing in the first Tunisian soccer league were evaluated three times (T1, T2, and T3) over 12 weeks. The non-congested period of match play was from T1 to T2, when the players played 6 games over 6 weeks. The congested period was from T2 to T3, when the players played 10 games over 6 weeks. From T1 to T3, players performed the Yo-Yo intermittent recovery test level 1 (YYIR1), the repeated shuttle sprint ability test (RSSA), the countermovement jump test (CMJ), and the squat jump test (SJ). Plasma Cortisol (C), Testosterone (T), and the T/C ratio were analyzed at T1, T2, and T3. Players had their mood dimensions (tension, depression, anger, vigor, fatigue, confusion, and a Total Mood Disturbance) assessed through the Profile of Mood State questionnaire (POMS). Training session rating of perceived exertion (sRPE) was also recorded on a daily basis in order to quantify internal training load and elements of monotony and strain.

Results

Significant performance declines (T1 < T2 < T3) were found for SJ performance (p = 0.04, effect size [ES] ES_1–2 = 0.15−0.06, ES_2–3 = 0.24) from T1 to T3. YYIR1 performance improved significantly from T1 to T2 and declined significantly from T2 to T3 (p = 0.001, ES_1–2 = 0.24, ES_2–3 = −2.54). Mean RSSA performance was significantly higher (p = 0.019, ES_1–2 = −0.47, ES_2–3 = 1.15) in T3 compared with T2 and T1. Best RSSA performance was significantly higher in T3 when compared with T2 and T1 (p = 0.006, ES_2–3 = 0.47, ES_1–2 = −0.56), but significantly lower in T2 when compared with to T1. T and T/C were significantly lower in T3 when compared with T2 and T1 (T: p = 0.03, ES_3–2 = −0.51, ES_3–1 = −0.51, T/C: p = 0.017, ES_3–2 = −1.1, ES_3–1 = −1.07). Significant decreases were found for the vigor scores in T3 when compared to T2 and T1 (p = 0.002, ES_1–2 = 0.31, ES_3–2 = −1.25). A significant increase was found in fatigue scores in T3 as compared to T1 and T2 (p = 0.002, ES_1–2 = 0.43, ES_2–3 = 0.81). A significant increase was found from T1 < T2 < T3 intension score (p = 0.002, ES_1–2 = 1.1, ES_2–3 = 0.2) and anger score (p = 0.03, ES_1–2 = 0.47, ES_2–3 = 0.33) over the study period. Total mood disturbance increased significantly (p = 0.02, ES_1–2 = 0.91, ES_2–3 = 1.1) from T1 to T3. Between T1-T2, significant relationships were observed between workload and changes in T (r = 0.66, p = 0.003), and T/C ratio (r = 0.62, p = 0.01). There were significant relationships between performance in RSSA_best and training load parameters (workload: r = 0.52, p = 0.03; monotony: r = 0.62, p = 0.01; strain: r = 0.62, p = 0.009). Between T2-T3, there was a significant relationship between Δ% of total mood disturbance and Δ% of YYIR1 (r = −0.54; p = 0.04), RSSA_best (r = 0.58, p = 0.01), SJ (r = −0,55, p = 0.01), T (r = 0.53; p = 0.03), and T/C (r = 0.5; p = 0.04).

Conclusion

An intensive period of congested match play significantly compromised elite soccer players’ physical and mental fitness. These changes were related to psychological but not hormonal parameters; even though significant alterations were detected for selected measures. Mood monitoring could be a simple and useful tool to determine the degree of preparedness for match play during a congested period in professional soccer.

Do You Transfer Your Skills? From Sports to Health Management in Cancer Patients

Skill transfer is a process where personal cognitive and behavioral abilities are applied to contexts that are different from the one in which they were originally learned. Literature demonstrates that skill transferability is possible: for example, people can apply skills learned in sports to other life-domains (such as school, work, or health management) with the aim to improve individual characteristics and reach personal goals. To do this, several factors, such as positive communication, adequate context, a person-centered perspective, and specific strategies, are necessary. On the basis of this, the aim of this contribution is explore the relationship between sports and health management skills to enhance the coach/athlete as well as the patient/physician relationships. Useful strategies for skill transfer from sports to cancer management are shown.

Biomarkers in Stress Related Diseases/Disorders: Diagnostic, Prognostic, and Therapeutic Values

Various internal and external factors negatively affect the homeostatic equilibrium of organisms at the molecular to the whole-body level, inducing the so-called state of stress. Stress affects an organism's welfare status and induces energy-consuming mechanisms to combat the subsequent ill effects; thus, the individual may be immunocompromised, making them vulnerable to pathogens. The information presented here has been extensively reviewed, compiled, and analyzed from authenticated published resources available on Medline, PubMed, PubMed Central, Science Direct, and other scientific databases. Stress levels can be monitored by the quantitative and qualitative measurement of biomarkers. Potential markers of stress include thermal stress markers, such as heat shock proteins (HSPs), innate immune markers, such as Acute Phase Proteins (APPs), oxidative stress markers, and chemical secretions in the saliva and urine. In addition, stress biomarkers also play critical roles in the prognosis of stress-related diseases and disorders, and therapy guidance. Moreover, different components have been identified as potent mediators of cardiovascular, central nervous system, hepatic, and nephrological disorders, which can also be employed to evaluate these conditions precisely, but with stringent validation and specificity. Considerable scientific advances have been made in the detection, quantitation, and application of these biomarkers. The present review describes the current progress of identifying biomarkers, their prognostic, and therapeutic values.

Biomarkers in Stress Related Diseases/Disorders: Diagnostic, Prognostic, and Therapeutic Values

Various internal and external factors negatively affect the homeostatic equilibrium of organisms at the molecular to the whole-body level, inducing the so-called state of stress. Stress affects an organism's welfare status and induces energy-consuming mechanisms to combat the subsequent ill effects; thus, the individual may be immunocompromised, making them vulnerable to pathogens. The information presented here has been extensively reviewed, compiled, and analyzed from authenticated published resources available on Medline, PubMed, PubMed Central, Science Direct, and other scientific databases. Stress levels can be monitored by the quantitative and qualitative measurement of biomarkers. Potential markers of stress include thermal stress markers, such as heat shock proteins (HSPs), innate immune markers, such as Acute Phase Proteins (APPs), oxidative stress markers, and chemical secretions in the saliva and urine. In addition, stress biomarkers also play critical roles in the prognosis of stress-related diseases and disorders, and therapy guidance. Moreover, different components have been identified as potent mediators of cardiovascular, central nervous system, hepatic, and nephrological disorders, which can also be employed to evaluate these conditions precisely, but with stringent validation and specificity. Considerable scientific advances have been made in the detection, quantitation, and application of these biomarkers. The present review describes the current progress of identifying biomarkers, their prognostic, and therapeutic values.

Heart rate variability, salivary cortisol and competitive state anxiety responses during pre-competition and pre-training moments

The study aimed to investigate physiological and psychological states prior to competition and prior to training in three different demanding activities. Eighteen canoe athletes, 18 street runners and 18 jiu-jitsu fighters were included in this study (n=54). The Competitive State Anxiety Inventory-2 (CSAI-2), salivary cortisol and heart rate variability (HRV) were measured at two time points (pre-training and pre-competition). Somatic anxiety (F_1,42 = 15.29, p = 0.0003), HRV (F_1,42 = 23.24, p < 0.0001) and salivary cortisol (F_1,42 = 22.96, p < 0.0001) were significantly greater at the pre-competition measurement point than at the pre-training point, but without a main effect of the type of athlete on these variables. A main effect of the type of athlete was found on somatic anxiety (F_2,42 = 6.58, p = 0.0033), cognitive anxiety (F_2,42 = 10.69, p = 0.0002) and self-confidence (F_2,42 = 5.42, p = 0.0080). Correlations between most CSAI-2 and physiological parameters were not significant (p > 0.05). In conclusion, the results indicated that both emotional indices and psychophysiological indices of stress are higher before competition than before training, with differences between emotional states between these sports. Although correlations between emotional states and psycho-physiological states before competition and before training were largely non-significant, these findings reinforce the importance of psychological monitoring of athletes in association with traditional physiological markers such as cortisol and HRV in sportive training programmes as complementary resources to improve both competition performance and the training routine.

Effects of training and competition on the sleep of elite athletes: a systematic review and meta-analysis

Objectives

To characterise the sleep of elite athletes and to identify factors associated with training and competition that negatively affect sleep.

Design

Prognosis systematic review.

Data sources

Three databases (PubMed, SCOPUS and SPORTDiscus) were searched from inception to 26 February 2018.

Eligibility criteria for selecting studies

Included studies objectively reported total sleep time (TST) and/or sleep efficiency (SE) in elite athletes. Studies were required to be observational or to include an observational trial.

Results

Fifty-four studies were included. During training, many studies reported athletes were unable to achieve TST (n=23/41) and/or SE (n=16/37) recommendations. On the night of competition, most studies reported athletes were unable to achieve TST (n=14/18) and/or SE (n=10/16) recommendations. TST was shorter (60 min) the night of competition compared with previous nights. SE was lower (1%) the night of competition compared with the previous night. TST was shorter the night of night competition (start ≥18:00; 80 min) and day competition (20 min) compared with the previous night. SE was lower (3%–4%) the night of night competition but unchanged the night of day competition compared with previous nights. Early morning training (start <07:00), increases in training load (>25%), late night/early morning travel departure times, eastward air travel and altitude ascent impaired sleep.

Conclusion

Athletes were often unable to achieve sleep recommendations during training or competition periods. Sleep was impaired the night of competition compared with previous nights. Early morning training, increases in training load, travel departure times, jet lag and altitude can impair athletes’ sleep.

PROSPERO registration number

CRD42017074367.

Salivary Biomarkers and Training Load During Training and Competition in Paralympic Swimmers

Context: Stress responses in athletes can be attributed to training and competition, where increased physiological and psychological stress may negatively affect performance and recovery. Purpose: To examine the relationship between training load (TL) and salivary biomarkers immunoglobulin A (IgA), alpha-amylase (AA), and cortisol across a 16-wk preparation phase and 10-d competition phase in Paralympic swimmers. Methods: Four Paralympic swimmers provided biweekly saliva samples during 3 training phases—(1) normal training, (2) intensified training, and (3) taper—as well as daily saliva samples in the 10-d Paralympic competition (2016 Paralympic Games). TL was measured using session rating of perceived exertion. Results: Multilevel analysis identified a significant increase in salivary immunoglobulin A (sIgA: 94.98 [27.69] μg·mL−1), salivary alpha-amylase (sAA: 45.78 [19.07] μg·mL−1), and salivary cortisol (7.92 [2.17] nM) during intensified training concurrent with a 38.3% increase in TL. During the taper phase, a 49.5% decrease in TL from the intensified training phase resulted in a decrease in sIgA, sAA, and salivary cortisol; however, all 3 remained higher than baseline levels. A further significant increase was observed during competition in sIgA (168.69 [24.19] μg·mL−1), sAA (35.86 [16.67] μg·mL−1), and salivary cortisol (10.49 [1.89] nM) despite a continued decrease (77.8%) in TL from the taper phase. Conclusions: Results demonstrate that performance in major competition such as Paralympic games, despite a noticeable reduction in TL, induces a stress response in athletes. Because of the elevated stress response observed, modifications to individual postrace recovery protocols may be required to enable athletes to maximize performance across all 10 d of competition.

The Variability of Sleep Among Elite Athletes

Practicing sport at the highest level is typically accompanied by several stressors and restrictions on personal life. Elite athletes’ lifestyle delivers a significant challenge to sleep, due to both the physiological and psychological demands, and the training and competition schedules. Inter-individual variability of sleep patterns (e.g., sleep requirements, chronotype) may have important implications not only for recovery and training schedules but also for the choice of measures to possibly improve sleep. This article provides a review of the current available literature regarding the variability of sleep among elite athletes and factors possibly responsible for this phenomenon. We also provide methodological approaches to better address the inter-individual variability of sleep in future studies with elite athletes. There is currently little scientific evidence supporting a specific influence of one particular type of sport on sleep; sleep disorders may be, however, more common in strength/power and contact sports. Sleep behavior may notably vary depending on the athlete’s typical daily schedule. The specificity of training and competition schedules possibly accounts for the single most influential factor leading to inconsistency in sleep among elite athletes (e.g., “social jet lag”). Additionally, athletes are affected by extensive exposure to electric light and evening use of electronic media devices. Therefore, the influence of ordinary sleep, poor sleep, and extended sleep as important additional contributors to training load should be studied. Future experimental studies on sleep and elite sport performance should systematically report the seasonal phase. Boarding conditions may provide a good option to standardize as many variables as possible without the inconvenience of laboratory. The use of interdisciplinary mixed-method approaches should be encouraged in future studies on sleep and elite sport. Finally, high inter- and intra-individual variability in the athletes’ sleep characteristics suggests a need for providing individual responses in addition to group means.

Does Elite Sport Degrade Sleep Quality? A Systematic Review

BACKGROUND

Information on sleep quality and insomnia symptomatology among elite athletes remains poorly systematised in the sports science and medicine literature. The extent to which performance in elite sport represents a risk for chronic insomnia is unknown.

OBJECTIVES

The purpose of this systematic review was to profile the objective and experienced characteristics of sleep among elite athletes, and to consider relationships between elite sport and insomnia symptomatology.

METHODS

Studies relating to sleep involving participants described on a pre-defined continuum of 'eliteness' were located through a systematic search of four research databases: SPORTDiscus, PubMed, Science Direct and Google Scholar, up to April 2016. Once extracted, studies were categorised as (1) those mainly describing sleep structure/patterns, (2) those mainly describing sleep quality and insomnia symptomatology and (3) those exploring associations between aspects of elite sport and sleep outcomes.

RESULTS

The search returned 1676 records. Following screening against set criteria, a total of 37 studies were identified. The quality of evidence reviewed was generally low. Pooled sleep quality data revealed high levels of sleep complaints in elite athletes. Three risk factors for sleep disturbance were broadly identified: (1) training, (2) travel and (3) competition.

CONCLUSION

While acknowledging the limited number of high-quality evidence reviewed, athletes show a high overall prevalence of insomnia symptoms characterised by longer sleep latencies, greater sleep fragmentation, non-restorative sleep, and excessive daytime fatigue. These symptoms show marked inter-sport differences. Two underlying mechanisms are implicated in the mediation of sport-related insomnia symptoms: pre-sleep cognitive arousal and sleep restriction.

Food restriction alters salivary cortisol and α-amylase responses to a simulated weightlifting competition without significant performance modification

The aim of this investigation was to evaluate the effect of a 6-day food restriction period on the physiological responses and performance of 11 high-level weightlifters. After a period of weight maintenance (T₂), they were assigned into two groups depending on whether they lost (Diet group, n = 6) or maintained their body weight (Control group, n = 5) during the course of those 6 days. An evaluation of performance and the measurement of salivary cortisol concentrations and salivary α-amylase (sAA) activity were performed during a simulated weightlifting competition which took place at T₂, after a 6-day period of food restriction (T₃). Dietary data were collected using a 6-day diet record. We noted a 41.8% decrease in mean energy intake during the dietary restriction period, leading to a 4.34% weight loss for the Diet group. Dietary restriction did not modify absolute performance levels, whilst a significant improvement was noted for the Control group. Furthermore, we noted a response of decreased salivary cortisol and increased sAA activity to the simulated competition stress at T₃ for the Diet group. These results may indicate that dietary reduction led to a dissociation of the hypothalamo-pituitary-adrenal axis and the sympatho-adreno-medullary system, which could impair training adaptations and absolute performance development.

Participating in university entrance exam despite repeated failure: a qualitative study of participants' experiences

OBJECTIVES

To explore the experiences of general practitioners who continue to sit a highly-competitive residency entrance examination, despite repeated failure.

METHODS

This qualitative, exploratory study employed semi-structured, in-depth interviews with 35 candidates of a residency entrance exam who had failed the examination at least twice and were preparing to sit it again. Interview questions addressed the challenges they faced and how they managed these challenges. Interview data were audiotaped, transcribed, and analysed to identify themes.

RESULTS

The results demonstrated that more than 50% (n=19) of candidates struggled continuously and internally with different aspects of the exam. These include being under a great deal of pressure to succeed, failing to prioritize study materials, inefficient review during the final days  of preparation, and sitting the exam with an afflicted body. Furthermore, during the examination, they frequently used inefficient strategies to answer questions. Afterwards, they experienced feelings of freedom associated with having finished the exam.

CONCLUSIONS

Participation in a highly-competitive examination exerts a considerable amount pressure on low-performing candidates. This climate not only results in burn out of participants, but it also influences their learning styles and identities as future physicians. It is therefore necessary to design a syllabus for both test candidates and policy makers, in order better to manage this environment. Candidates also should be aware of their individual weaknesses in order to improve their studying skills.