Trehalose Improved 20-min Cycling Time-Trial Performance After 100-min Cycling in Amateur Cyclists

Carbohydrate (CHO) supplementation during endurance exercise can improve performance. However, it is unclear whether low glycemic index (GI) CHO leads to differential ergogenic and metabolic effects compared with a standard high GI CHO. This study investigated the ergogenic and metabolic effects of CHO supplementation with distinct GIs, namely, (a) trehalose (30 g/hr), (b) isomaltulose (30 g/hr), (c) maltodextrin (60 g/hr), and (d) placebo (water). In this double-blind, crossover, counterbalanced, placebo-controlled study, 13 male cyclists cycled a total of 100 min at varied exercise intensity (i.e., 10-min stages at 1.5, 2.0, and 2.5 W/kg; repeated three times plus two 5-min stages at 1.0 W/kg before and after the protocol), followed by a 20-min time trial on four separated occasions. Blood glucose and lactate (every 20 min), heart rate, and ratings of perceived exertion were collected throughout, and muscle biopsies were taken before and immediately after exercise. The results showed that trehalose improved time-trial performance compared with placebo (total work done 302 ± 39 vs. 287 ± 48 kJ; p = .01), with no other differences between sessions (all p ≥ .07). Throughout the 100-min protocol, blood glucose was higher with maltodextrin compared with the other supplements at all time points (all p < .05). Heart rate, ratings of perceived exertion, muscle glycogen content, blood glucose, and lactate were not different between conditions when considering the 20-min time trial (all p > .05). Trehalose supplementation throughout endurance exercise improved cycling performance and appears to be an appropriate CHO source for exercise tasks up to 2 hr. No ergogenic superiority between the different types of CHO was established.

How Cool is That? The Effects of Menthol Mouth Rinsing on Exercise Capacity and Performance: A Systematic Review and Meta-analysis

BACKGROUND

Menthol (MEN) mouth rinsing (MR) has gained considerable interest in the athletic population for exercise performance; however, the overall magnitude of effect is unknown.

OBJECTIVE

The aim of this systematic review and meta-analysis was to determine the efficacy of menthol MEN MR and the impact it has on exercise capacity and performance.

METHODS

Three databases were searched with articles screened according to the inclusion/exclusion criteria. Three-level meta-analyses were used to investigate the overall efficacy of MEN MR and the impact it has on exercise capacity and performance. Meta-regressions were then performed with 1) mean VO2peak, 2) MEN swilling duration; 3) the MEN concentration of MR solution, 4) the number of executed swills throughout a single experiment, 5) the use of flavoured sweetened, non-caloric, or non-flavoured neutral solutions as controls, 6) mean environmental temperature at the time of exercise tests, and 7) exercise type as fixed factors to evaluate their influence on the effects of MEN MR.

RESULTS

Ten MEN MR studies included sufficient information pertaining to MEN MR and exercise performance and capacity. MR with MEN resulted in no significant change in capacity and performance (SMD = 0.12; 95% CI - 0.08, 0.31; p = 0.23, n = 1, tau21 < 0.0001, tau22 =  < 0.0001, I2 = 0%). No significant influence was detected in meta-regressions for VO2peak, (estimate: 0.03; df = 8; 95% CI - 0.03, 0.09; p = 0.27), swilling duration (5 vs. 10 s: 0.00; df = 16; 95% CI - 0.41, 0.41; p = 1.0), MEN concentration (low [0.01%] vs. high [0.1%]: - 0.08; df = 15; 95% CI - 0.49, 0.32; p = 0.67), number of swills (estimate: 0.02; df = 13; 95% CI - 0.05, 0.09; p = 0.56), the use of flavoured sweetener or non-caloric as control (non-flavoured vs. flavoured: 0.12; df = 16; 95% CI - 0.30, 0.55; p = 0.55) or mean room temperature during exercise tests (estimate: 0.01; df = 16; 95% CI - 0.02, 0.04; p = 0.62).

CONCLUSION

MEN MR did not significantly improve overall exercise capacity and performance, though those involved in endurance exercise may see benefits.

Optimising physiotherapy for people with lateral elbow tendinopathy - Results of a mixed-methods pilot and feasibility randomised controlled trial (OPTimisE)

BACKGROUND

The OPTimisE intervention was developed to address uncertainty regarding the most effective physiotherapy treatment strategy for people with Lateral Elbow Tendinopathy (LET).

OBJECTIVES

To assess the feasibility of conducting a fully-powered randomised controlled trial (RCT) evaluating whether the OPTimisE intervention is superior to usual physiotherapy treatment for adults with LET.

DESIGN

A mixed-methods multi-centred, parallel pilot and feasibility RCT, conducted in three outpatient physiotherapy departments in the UK.

METHOD

Patients were independently randomised 1:1 in mixed blocks, stratified by site, to the OPTimisE intervention or usual care. Outcomes were assessed using pre-defined feasibility progression criteria.

RESULTS

50 patients were randomised (22 Female, 28 Male), mean age 48 years (range 27-75). Consent rate was 71% (50/70), fidelity to intervention 89% (16/18), attendance rate in the OPTimisE group 82% (55/67) vs 85% (56/66) in usual care, outcome measure completion 81% (39/48) at six-month follow-up. There were no related adverse events. Patients and physiotherapists reported that the OPTimisE intervention was acceptable but suggested improvements to the trial design. 49 patients were recruited from physiotherapy referrals vs one from primary care records. Outcome measure return rates were higher when completed online (74%) compared to postal questionnaire (50%). Exploratory analysis showed improvements in both groups over time.

CONCLUSIONS

It is methodologically feasible to conduct a fully powered RCT comparing the clinical and cost-effectiveness of the OPTimisE intervention versus usual physiotherapy treatment. Considering the similar improvements observed in both groups, careful consideration is needed regarding the priority research question to be addressed in future research.

Caffeine, CYP1A2 Genotype, and Exercise Performance: A Systematic Review and Meta-analysis

PURPOSE

This study aimed to summarize and meta-analyze existing evidence regarding the influence of CYP1A2 genotypes on the acute effects of caffeine for exercise performance and to investigate the interaction between genotype, dosage, and timing of caffeine supplementation.

METHODS

Six databases were searched for studies determining the effect of caffeine (except mouth rinsing) on exercise performance between CYP1A2 genotypes. Three-level meta-analyses were performed using standardized mean differences (SMD; Hedge's g ) to determine the effect of caffeine on exercise outcomes within and between CYP1A2 genotypes (AA, AC, and CC). Meta-regressions were performed for dose, timing, and presence of reported conflict of interests (RCOI). A meta-analysis was also performed with placebo values to assess for imbalances between genotypes.

RESULTS

Thirteen studies, totaling 119 outcomes and 440 participants, were included (233 AA, 175 AC, ad 34 CC). Caffeine improved performance for AA (SMD = 0.30, 95% confidence interval [CI] = 0.21-0.39, P < 0.0001) and AC (SMD = 0.16, 95% CI = 0.06-0.25, P = 0.022) but worsened performance for CC (SMD = -0.22, 95% CI = -0.44 to -0.01, P < 0.0001). Dose affected only CC, with greater doses generating more positive SMD (CC-dose estimate: +0.19/1 mg·kg -1 body mass, 95% CI = 0.04-0.33, P = 0.01). Timing influenced only CC, with better performance with later onset of exercise after supplementation (CC-timing estimate: +0.01/min, 95% CI = 0.00-0.02, P = 0.02). RCOI only affected SMD of CC (CC-RCOI estimate: -0.57, 95% CI = -1.02 to -0.12, P = 0.01). After excluding studies with RCOI, no influence of genotype was seen (all P ≥ 0.19). Small, nonsignificant differences were seen in placebo between genotypes (SMD AA vs CC: -0.13; AA vs AC: -0.12; AC vs CC: -0.05; all P ≥ 0.26).

CONCLUSIONS

Caffeine improved performance for AA and AC but worsened performance for CC. Dose and timing moderated the efficacy of caffeine for CC only. Caution is advised because baseline differences and studies with RCOI could have influenced these results.

Does sodium bicarbonate based extra-cellular buffering support reduce high intensity exercise-induced fatigue and enhance short-term recovery assessed by selected blood biochemical indices?

Exercise-induced metabolic processes induce muscle acidification which contributes to a reduction in the ability to perform repeated efforts. Alkalizing agents such as sodium bicarbonate (NaHCO3) prevent large blood pH changes, however, there is no evidence on whether regulation of acid-base balance may also support whole body homeostasis monitored through heamatological and biochemical blood markers in a dose-dependent manner. Thirty Cross-Fit-trained participants were studied in a randomized, multi cross-over, placebo (PLA)-controlled double-blind manner in which they performed a control session (CTRL, without supplementation), three NaHCO3 visits (three different doses) and PLA (sodium chloride in an equimolar amount of sodium as NaHCO3). Each visit consisted of two 30-s Wingate tests separated by CrossFit-specific benchmarks (Wall Balls and Burpees - both performed for 3 min). Blood samples were collected at rest, immediately post-exercise and after 45 min recovery. Significant differences between visits appeared for blood pH, percentage of lymphocytes and granulocytes, red blood cells count and haemoglobin concentration at post-exercise and 45-min recovery, and for white blood cells count, percentage of monocytes, concentration of magnesium and creatinine at 45-min recovery. Most of the observed differences for heamatological and biochemical markers were significant compared to CTRL, but not different after PLA. NaHCO3 supplementation compared to PLA did not significantly affect exercise or recovery shifts in studied blood indicators. However, the changes in these markers after NaHCO3 and PLA in relation to CTRL indicate a possible role of sodium.

Use of Buffers in Specific Contexts: Highly Trained Female Athletes, Extreme Environments and Combined Buffering Agents-A Narrative Review

This narrative review evaluated the evidence for buffering agents (sodium bicarbonate, sodium citrate and beta-alanine), with specific consideration of three discrete scenarios: female athletes, extreme environments and combined buffering agents. Studies were screened according to exclusion and inclusion criteria and were analysed on three levels: (1) moderating variables (supplement dose and timing, and exercise test duration and intensity), (2) design factors (e.g., use of crossover or matched group study design, familiarisation trials) and (3) athlete-specific factors (recruitment of highly trained participants, buffering capacity and reported performance improvements). Only 19% of the included studies for the three buffering agents reported a performance benefit, and only 10% recruited highly trained athletes. This low transferability of research findings to athletes' real-world practices may be due to factors including the small number of sodium citrate studies in females (n = 2), no studies controlling for the menstrual cycle (MC) or menstrual status using methods described in recently established frameworks, and the limited number of beta-alanine studies using performance tests replicating real-world performance efforts (n = 3). We recommend further research into buffering agents in highly trained female athletes that control or account for the MC, studies that replicate the demands of athletes' heat and altitude camps, and investigations of highly trained athletes' use of combined buffering agents. In a practical context, we recommend developing evidence-based buffering protocols for individual athletes which feature co-supplementation with other evidence-based products, reduce the likelihood of side-effects, and optimise key moderating factors: supplement dose and timing, and exercise duration and intensity.

Effect of menstrual cycle and contraceptive pill phase on aspects of exercise physiology and athletic performance in female athletes: protocol for the Feminae international multisite innovative project

The idiom 'more high-quality research is needed' has become the slogan for sport and exercise physiology-based research in female athletes. However, in most instances, it is challenging to address this gap of high-quality research in elite female athletes at a single study site due to challenges in recruiting enough participants with numerous menstrual cycle and contraceptive pill permutations. Accordingly, we have assembled an international multisite team to undertake an innovative project for female athletes, which investigates the effects of changes in endogenous and exogenous oestrogen and progesterone/progestins across the menstrual cycle and in response to second-generation combined monophasic contraceptive pill use, on aspects of exercise physiology and athletic performance. This project will employ the current gold-standard methodologies in this area, resulting in an adequately powered dataset. This protocol paper describes the consortium-based approach we will undertake during this study.

A cloth facemask increased ratings of perceived exertion and reduced affect, without affecting sprint or muscular performance

We determined the effects of wearing a cloth facemask on exercise performance and subjective responses during training of track and field athletes. Track and field athletes (n = 10, sprinters and long jumpers) performed two training sessions with and without a three-layered antiviral cloth facemask. The training session simulated the specific demands of the sport, consisting of five 30-m sprints, interspersed with passive 4-min intervals. Countermovement jump performance was assessed pre- and post-sprints, and ratings of perceived exertion (RPE) and affect were collected throughout. There was no evidence of condition*time interactions for sprint time (P = 0.21) or acceleration (P = 0.47). There was weak evidence of a condition effect on RPE (P = 0.05), though no condition*time interaction (P = 0.35). There was moderate evidence of a condition*time interaction for affect (P = 0.02), with lower ratings following sprints 3, 4 and 5 when using the mask. These findings suggest that wearing a mask may negatively impact subjective feelings of training without necessarily harming sprint performance.

The interplay between bicarbonate kinetics and gastrointestinal upset on ergogenic potential after sodium bicarbonate intake: a randomized double-blind placebo-controlled trial

This double-blind placebo-controlled cross-over study utilized comprehensive monitoring of blood bicarbonate (HCO₃^¯) kinetics and evaluation of gastrointestinal (GI) upset to determine their impact on an ergogenic potential of sodium bicarbonate (SB) co-ingested with carbohydrate (CHO). Nineteen CrossFit athletes performed 6 bouts of 15 s Wingate Anaerobic Test (WAnT) 90 min post-ingestion of 0.4 g·kg^-1 body mass (BM) of SB (SB + CHO treatment) or PLA (PLA + CHO treatment) with 15 g CHO. Blood HCO₃^¯ concentration was evaluated at baseline, 30-, 60-, 75- and 90 min post-ingestion, in between WAnT bouts, and 3 and 45 min post-exercise, while GI upset at 120 min after protocol started. Control (no supplementation; CTRL) procedures were also performed. An effective elevation of extra-cellular buffering capacity was observed 60-90 min post-ingestion of SB + CHO. At mean peak blood HCO₃^¯, or at start of exercise an increase > 6 mmol·L^-1 in HCO₃^¯ was noted in 84% and 52.6% participants, respectively. SB + CHO did not prevent performance decrements in WAnT bouts. There were no significant relationships between changes in blood HCO₃^¯ and WAnTs' performance. Total GI was significantly higher in SB + CHO compared to CTRL, and stomach problems in SB + CHO compared to CTRL and PLA + CHO. There were inverse associations between peak- (p = 0.031; r = - 0.495), average- (p = 0.002; r = - 0.674) and minimum power (p = 0.008; r = - 0.585) and total GI upset, as well as average power and severe GI distress (p = 0.042; r = - 0.471) at SB + CHO. The implemented dose of SB + CHO was effective in improving buffering capacity, but did not prevent decrements in WAnTs' performance. GI side effects were crucial in affecting the ergogenic potential of SB and thus must be insightfully monitored in future studies.

Dietary β-Alanine Intake Assessed by Food Records Does Not Associate With Muscle Carnosine Content in Healthy, Active, Omnivorous Men and Women

β-Alanine (BA) is one of the most widely used sport supplements, due to its capacity to improve high-intensity exercise performance by increasing muscle carnosine (MCarn) content, and consequently, the buffering capacity of the muscle. BA is also available in a variety of animal foods, but little is currently known about the influence of dietary BA intake on MCarn. The aim of the current study was to compile a detailed summary of available data on the BA content of commonly consumed foods, and to explore whether associations could be detected between self-reported dietary BA intake and skeletal MCarn in a group of 60 healthy, active, omnivorous men and women. Dietary BA intake was assessed via 3-day food records, and MCarn content assessed by high-performance liquid chromatography. A series of univariate and multivariate linear regression models were used to explore associations between estimated dietary BA and MCarn. No evidence of associations between dietary BA intake and MCarn were identified, with effect sizes close to zero calculated from models accounting for key demographic variables (f2 ≤ 0.02 for all analyses). These findings suggest that capacity to increase MCarn via dietary strategies may be limited, and that supplementation may be required to induce increases of the magnitude required to improve performance.

Caffeine and sport

Caffeine is a trimethylxanthine found in coffee and several other foods and beverages. Its stimulatory effects make it an interesting strategy to boost performance for athletic populations. Scientific evidence supports its efficacy to improve high-intensity endurance exercise, explosive and high-intensity efforts, resistance exercise, team sports and combat sports, though individual variation in the ergogenic response to caffeine exists. Supplementation can be taken in many forms including dissolved in water, via capsules, coffee, energy drinks and caffeinated gum; ingestion via capsules, dissolved in water or in caffeinated gum appear to be most effective. Variability in the exercise response following caffeine supplementation may be explained by genetic factors or habitual caffeine consumption. Caffeine is an excellent supplement for athletes looking to improve their exercise performance, though some consideration of side-effects and impact on sleep are warranted.

Patients' and clinicians' perspectives towards primary care consultations for shoulder pain: qualitative findings from the Prognostic and Diagnostic Assessment of the Shoulder (PANDA-S) programme

BACKGROUND

Clinical management of musculoskeletal shoulder pain can be challenging due to diagnostic uncertainty, variable prognosis and limited evidence for long-term treatment benefits. The UK-based PANDA-S programme (Prognostic And Diagnostic Assessment of the Shoulder) is investigating short and long-term shoulder pain outcomes. This paper reports linked qualitative research exploring patients' and clinicians' views towards primary care consultations for shoulder pain.

METHODS

Semi-structured interviews were conducted with 24 patients and 15 primary care clinicians. Twenty-two interviews (11 patients, 11 clinicians) were conducted as matched patient-clinician 'dyads'. Data were analysed thematically.

RESULTS

Clinicians reported attempts to involve patients in management decisions; however, there was variation in whether patients preferred treatment choice, or for decisions to be clinician-led. Some patients felt uncertain about the decisions made, due to a lack of discussion about available management options. Many General Practitioners expressed a lack of confidence in diagnosing the underlying cause of shoulder pain. Patients reported either not being given a diagnosis, or receiving different diagnoses from different professionals, resulting in confusion. Whilst clinicians reported routinely discussing prognosis of shoulder pain, patients reported that prognosis was not raised. Patients also expressed concern that their shoulder pain could be caused by serious pathology; however, clinicians felt that this was not a common concern for patients.

CONCLUSIONS

Findings showed disparities between patients' and clinicians' views towards shoulder pain consultations, indicating a need for improved patient-clinician communication. Findings will inform the design of an intervention to support treatment and referral decisions for shoulder pain that will be tested in a randomised controlled trial.

Performing moderate to severe activity is safe and tolerable for healthy youth while wearing a cloth facemask

OBJECTIVE

To investigate if a cloth facemask could affect physiological and perceptual responses to exercise at distinct exercise intensities in healthy young individuals.

METHODS

Nine participants (sex, female/male: 6/3; age: 13±1 years; VO2peak: 44.5±5.5 mL/kg/min) underwent a progressive square-wave test at four intensities: (1) 80% of ventilatory anaerobic threshold (VAT), (2) VAT, and (3) 40% between VAT and [Formula: see text] wearing a triple-layered cloth facemask or not. Participants then completed a final stage to exhaustion at a running speed equivalent to the maximum achieved during the cardio-respiratory exercise test (Peak). Physiological, metabolic, and perceptual measures were measured.

RESULTS

Mask did not affect spirometry (forced vital capacity, peak expiratory flow, forced expiratory volume; all p≥0.27), respiratory (inspiratory capacity, end-expiratory volume [EELV] to functional vital capacity ratio, EELV, respiratory frequency [Rf], tidal volume [VT], Rf/VT, end-tidal carbo dioxide pressure, ventilatory equivalent to carbon dioxide ratio; all p≥0.196), hemodynamic (heart rate, systolic and diastolic blood pressure; all p>0.41), ratings of perceived exertion (p = 0.04) or metabolic measures (lactate; p = 0.78) at rest or at any exercise intensity.

CONCLUSIONS

This study shows that performing moderate to severe activity is safe and tolerable for healthy youth while wearing a cloth facemask.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04887714.

Delegation of workload from musculoskeletal physiotherapists to physiotherapy assistants/support workers: A UK online survey

PURPOSE

There are approximately 9000 physiotherapy assistants/support workers in the UK. Many of them work in NHS physiotherapy outpatient services treating patients with musculoskeletal conditions, but their role(s) are relatively undefined and as such there is considerable variation in the duties and tasks they undertake. This study aimed to explore current practice of UK musculoskeletal physiotherapists in relation to delegation to physiotherapy assistants/support workers.

METHODS

An online cross-sectional descriptive survey was designed and collected data on delegation practice and training in delegation. The survey was piloted with 10 physiotherapists. The final questionnaire was distributed via the interactive Chartered Society of Physiotherapy's website and the authors' professional networks via Twitter. Responses were collected over a five-week-period from October to November 2020.

RESULTS

Of 302 survey responses, 232 were analysed (46 incomplete, 24 ineligible). The majority of respondents (66.3%, 154/232) had worked as physiotherapists for over 10 years. Most respondents indicated they had neither formal training (84%, 195/232) nor informal training (60.3%, 140/232) regarding how to delegate tasks. The clinical tasks most commonly delegated by physiotherapists were supervision of exercises (81.0%, 188/232) and walking aid provision (78.5%, 182/232) whereas the least delegated clinical task was the application of electrotherapy (19.8%, 46/232).

CONCLUSION

These survey results provide evidence for the need to improve training in delegation for both physiotherapists and physiotherapy assistants, and to ensure clearer delegation processes to facilitate good delegation practice in the musculoskeletal setting.

Can the Brazilian Caffeine Expectancy Questionnaires Differentiate the CYP1A2 and ADORA2A Gene Polymorphisms?-An Exploratory Study with Brazilian Athletes

This study investigated the ability of the Brazilian Caffeine Expectancy Questionnaire (CaffEQ-BR), full and brief versions, to differentiate genetic profiles regarding the polymorphisms of the CYP1A2 (rs 762551) and ADORA2A (rs 5751876) genes in a cohort of Brazilian athletes. One-hundred and fifty participants were genotyped for CYP1A2 and ADORA2A. After the recruitment and selection phase, 71 (90% male and 10% female, regular caffeine consumers) completed the CaffEQ-BR questionnaires and a self-report online questionnaire concerning sociodemographic data, general health status, and frequency of caffeine consumption. The order of completion of the CaffEQ-BR questionnaires was counterbalanced. The concordance between the full and brief versions of the CaffEQ-BR was analyzed using the intraclass correlation coefficient (ICC). To determine the discriminatory capacity of the questionnaires for genotype, the receiver operating characteristic (ROC) curve was applied for sensitivity and specificity (significance level of 5%). Mean caffeine intake was 244 ± 161 mg·day−1. The frequency of AA genotypes for CYP1A2 was 47.9% (n = 34) and 52.1% (n = 37) for C-allele carriers (AC and CC). The frequencies of TT genotypes for ADORA2A were 22.7% (n = 15) and 77.3% (n = 51) for C-allele carriers (TC and CC). All CaffEQ-BR factors, for the full and brief versions, were ICCs > 0.75, except for factor 6 (anxiety/negative effects; ICC = 0.60), and presented ROC curve values from 0.464 to 0.624 and 0.443 to 0.575 for CYP1A2 and ADORA2A. Overall, the CaffEQ-BR (full and brief versions) did not show discriminatory capacity for CYP1A2 and ADORA2A gene polymorphisms. In conclusion, the CaffEQ-BR was not able to differentiate genotypes for the CYP1A2 or ADORA2A genes in this group of Brazilian athletes.

Comparing an optimised physiotherapy treatment package with usual physiotherapy care for people with tennis elbow - protocol for the OPTimisE pilot and feasibility randomised controlled trial

BACKGROUND

Physiotherapy is recommended for people with tennis elbow, but whilst a wide array of treatments is available, the optimal approach remains uncertain. We have therefore recently developed an optimised physiotherapy treatment package for tennis elbow based on a synthesis of the evidence, patient input and clinical consensus. It consists of detailed advice and education, a structured progressive exercise programme and provision of a counter-force elbow brace. Here, we report the protocol for our multicentre pilot and feasibility randomised controlled trial (RCT) designed to (a) examine the feasibility of our optimised physiotherapy treatment package and (b) to pilot trial processes for a future fully powered RCT to test clinical and cost-effectiveness compared with usual physiotherapy treatment.

METHODS

A multicentre pilot and feasibility RCT will be conducted across three sites in England, recruiting up to 50 patients (or for a maximum of 12 months). Participants with tennis elbow, identified from physiotherapy clinic waiting lists and general practice surgeries, will be randomly allocated to receive the optimised physiotherapy treatment package or usual physiotherapy care. Analysis will focus on feasibility measures including consent rate, intervention fidelity, follow-up rate and outcome completion rate. A nested qualitative study will explore the acceptability of the study processes and patient and physiotherapist experiences of the new optimised intervention.

DISCUSSION

This study will determine the feasibility of a new optimised physiotherapy treatment package for people with tennis elbow and pilot the processes for a future fully powered RCT. In the longer term, this treatment package may provide superior clinical outcomes for patients, in terms of pain and quality of life, and be more cost-effective for the health service.

TRIAL REGISTRATION

Registered with the ISRCTN database 19/7/2021, https://www.isrctn.com/ISRCTN64444585.

Factors that Moderate the Effect of Nitrate Ingestion on Exercise Performance in Adults: A Systematic Review with Meta-Analyses and Meta-Regressions

To identify how variables such as exercise condition, supplementation strategy, participant characteristics and demographics, and practices that control oral microbiota diversity could modify the effect of inorganic nitrate ingestion (as nitrate salt supplements, beetroot juice, and nitrate-rich vegetables) on exercise performance, we conducted a systematic review with meta-analysis. Studies were identified in PubMed, Embase, and Cochrane databases. Eligibility criteria included randomized controlled trials assessing the effect of inorganic nitrate on exercise performance in healthy adults. To assess the variation in effect size, we used meta-regression models for continuous variables and subgroup analysis for categorical variables. A total of 123 studies were included in this meta-analysis, comprising 1705 participants. Nitrate was effective for improving exercise performance (standardized mean difference [SMD]: 0.101; 95% CI: 0.051, 0.151, P <0.001, I2 = 0%), although nitrate salts supplementation was not as effective (P = 0.629) as ingestion via beetroot juice (P <0.001) or a high-nitrate diet (P = 0.005). Practices that control oral microbiota diversity influenced the nitrate effect, with practices harmful to oral bacteria decreasing the ergogenic effect of nitrate. The ingestion of nitrate was most effective for exercise lasting between 2 and 10 min (P <0.001). An inverse dose-response relation between the fraction of inspired oxygen and the effect size (coefficient: -0.045, 95% CI: -0.085, -0.005, P = 0.028) suggests that nitrate was more effective in increasingly hypoxic conditions. There was a dose-response relation for acute administration (P = 0.049). The most effective acute dose was between 5 and 14.9 mmol provided ≥150 min prior to exercise (P <0.001). An inverse dose-response for protocols ≥2 d was observed (P = 0.025), with the optimal dose between 5 and 9.9 mmol·d-1 (P <0.001). Nitrate, via beetroot juice or a high-nitrate diet, improved exercise performance, in particular, in sessions lasting between 2 and 10 min. Ingestion of 5-14.9 mmol⋅d-1 taken ≥150 min prior to exercise appears optimal for performance gains and athletes should be aware that practices controlling oral microbiota diversity may decrease the effect of nitrate.

Acute effects of beetroot juice and caffeine co-ingestion during a team-sport-specific intermittent exercise test in semi-professional soccer players: a randomized, double-blind, placebo-controlled study

BACKGROUND

Beetroot juice (BJ) and caffeine (CAF) are considered as ergogenic aids among athletes to enhance performance, however, the ergogenic effects of BJ and CAF co-ingestion are unclear during team-sport-specific performance. This study aimed to investigate the acute effects of BJ and CAF co-ingestion on team-sport-specific performance, compared with placebo (PL), BJ, and CAF alone.

METHOD

Sixteen semi-professional male soccer players (age: 19.8 ± 2.2 years, body mass: 69.2 ± 6.1 kg, height: 177.3 ± 6.0 cm) completed four experimental trials using a randomized, double-blind study design: BJ + CAF, CAF + PL, BJ + PL, and PL + PL. Countermovement jump with arm swing (CMJAS) performance and cognitive function by Stroop Word-Color test were evaluated before and after the Yo-Yo Intermittent Recovery Test level 1 (YYIR1). Also, rate of perceived exertion (RPE), heart rate, and gastrointestinal (GI) discomfort were measured during each session.

RESULTS

No significant differences were shown between test conditions for total distance covered in YYIR1 (BJ + CAF: 1858 ± 455 m, CAF + PL: 1798 ± 422 m, BJ + PL: 1845 ± 408 m, PL + PL 1740 ± 362 m; p = 0.55). Moreover, CMJAS performance, cognitive function, and RPE during the YYIR1 were not significantly different among conditions (p > 0.05). However, the average heart rate during the YYIR1 was higher in CAF + PL compared to PL + PL (by 6 ± 9 beats/min; p < 0.05), and GI distress was greater in BJ + CAF compared to PL + PL (by 2.4 ± 3.6 a.u.; p < 0.05).

CONCLUSION

These results suggest, neither acute co-ingestion of BJ + CAF nor BJ or CAF supplementation alone significantly affected team-sport-specific performance compared to the PL treatment.

Effects of caffeine chewing gum supplementation on exercise performance: a systematic review and meta-analysis

The aim of this systematic review with meta-analysis was to determine the effect of caffeine gum (Caff-gum) on exercise performance-related outcomes. Medline, EmBase, and SPORTSDiscus, and the register ClinicalTrials.gov were searched in March 2021, for studies assessing the effect of Caff-gum in placebo-controlled protocols involving healthy adults (i.e., with no chronic diseases or health conditions). Risk of bias was assessed using the RoB 2 tool. Random-effects meta-analyses using standardized mean differences (SMD) were performed to determine the effect of Caff-gum on exercise outcomes with several sub-analyses (training status, exercise type, timing and dose) for potential modifying factors. 14 studies were included, totaling 200 participants. There was a significant overall effect of Caff-gum compared to placebo (SMD = 0.21, 95%CI: 0.10-0.32; p = 0.001). Subgroup analysis showed improved performance for trained (SMD = 0.23, 95%CI: 0.08-0.37; p = 0.004), but not for untrained (SMD = 0.14, 95%CI: -0.02-0.29; p = 0.07) individuals. Caff-gum improved both endurance (SMD = 0.27, 95%CI: 0.12-0.42; p = 0.002) and strength/power (SMD = 0.20, 95%CI: 0.03-0.37; p = 0.03) performance outcomes. Caff-gum was ergogenic when consumed within 15 min prior to initiating exercise (SMD = 0.27, 95%CI: 0.07-0.4; p = 0.01), but not when provided >15 min prior (SMD=-0.48, 95%CI= -1.7-0.82; p = 0.25). There was no significant effect of Caff-gum with doses <3 mg/kg body mass (BM) (SMD = 0.20, 95%CI: -0.03-0.43; p = 0.07), but there was a significant effect when the dose was ≥3 mg/kg BM (SMD = 0.22, 95%CI: 0.07-0.37; p = 0.01). Caff-gum supplementation may be an effective ergogenic strategy for trained athletes involved in both endurance and strength/power exercise, using a recommended dose of ≥3 mg/kg BM consumed within 15 minutes before the exercise.

Extracellular Buffering Supplements to Improve Exercise Capacity and Performance: A Comprehensive Systematic Review and Meta-analysis

BACKGROUND

Extracellular buffering supplements [sodium bicarbonate (SB), sodium citrate (SC), sodium/calcium lactate (SL/CL)] are ergogenic supplements, although questions remain about factors which may modify their effect.

OBJECTIVE

To quantify the main effect of extracellular buffering agents on exercise outcomes, and to investigate the influence of potential moderators on this effect using a systematic review and meta-analytic approach.

METHODS

This study was designed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three databases were searched for articles that were screened according to inclusion/exclusion criteria. Bayesian hierarchical meta-analysis and meta-regression models were used to investigate pooled effects of supplementation and moderating effects of a range of factors on exercise and biomarker responses.

RESULTS

189 articles with 2019 participants were included, 158 involving SB supplementation, 30 with SC, and seven with CL/SL; four studies provided a combination of buffering supplements together. Supplementation led to a mean estimated increase in blood bicarbonate of + 5.2 mmol L^-1 (95% credible interval (CrI) 4.7-5.7). The meta-analysis models identified a positive overall effect of supplementation on exercise capacity and performance compared to placebo [ES_0.5 = 0.17 (95% CrI 0.12-0.21)] with potential moderating effects of exercise type and duration, training status and when the exercise test was performed following prior exercise. The greatest ergogenic effects were shown for exercise durations of 0.5-10 min [ES_0.5 = 0.18 (0.13-0.24)] and > 10 min [ES_0.5 = 0.22 (0.10-0.33)]. Evidence of greater effects on exercise were obtained when blood bicarbonate increases were medium (4-6 mmol L^-1) and large (> 6 mmol L^-1) compared with small (≤ 4 mmol L^-1) [β_Small:Medium = 0.16 (95% CrI 0.02-0.32), β_Small:Large = 0.13 (95% CrI - 0.03 to 0.29)]. SB (192 outcomes) was more effective for performance compared to SC (39 outcomes) [β_SC:SB = 0.10 (95% CrI - 0.02 to 0.22)].

CONCLUSIONS

Extracellular buffering supplements generate large increases in blood bicarbonate concentration leading to positive overall effects on exercise, with sodium bicarbonate being most effective. Evidence for several group-level moderating factors were identified. These data can guide an athlete's decision as to whether supplementation with buffering agents might be beneficial for their specific aims.

Combined but Not Isolated Ingestion of Caffeine and Taurine Improves Wingate Sprint Performance in Female Team-Sport Athletes Habituated to Caffeine

Previous studies have investigated caffeine (CAF) and taurine (TAU) in isolation and combined during exercise in males. However, the potential synergistic effect during high-intensity exercise remains unknown in female athletes. Seventeen female team-sport athletes participated (age: 23.4 ± 2.1 years; height: 1.68 ± 0.05 m; body mass: 59.5 ± 2.2 kg). All participants were habitual caffeine consumers (340.1 ± 28.6 mg/day). A double-blind randomized crossover design was used. Participants completed four experimental trials: (i) CAF and TAU (6 mg/kg body mass of CAF + 1 g of TAU), (ii) CAF alone; (iii) TAU alone; and (iv) placebo (PLA). Supplements were ingested 60 min before a 30-s Wingate Anaerobic Test (WAnT). Heart rate and blood lactate (BL) were measured before and immediately after the WAnT; and ratings of perceived exertion (RPE) were recorded immediately after the WAnT. Peak power (PP) was significantly higher following co-ingestion of CAF+TAU compared to PLA (p = 0.03) and TAU (p = 0.03). Mean power (MP) was significantly higher following co-ingestion of CAF+TAU compared to PLA (p = 0.01). No other differences were found between conditions for PP and MP (p > 0.05). There were also no observed differences in fatigue index (FI), BL; heart rate; and RPE between conditions (p > 0.05). In conclusion, compared to PLA the combined ingestion of 6 mg/kg of CAF and 1 g of TAU improved both PP and MP in female athletes habituated to caffeine; however; CAF and TAU independently failed to augment WAnT performance.

Extracellular pH, osmolarity, temperature and humidity could discourage SARS-CoV-2 cell docking and propagation via intercellular signaling pathways

The COVID-19 pandemic and its virus variants continue to pose a serious and long-lasting threat worldwide. To combat the pandemic, the world's largest COVID-19 vaccination campaign is currently ongoing. As of July 19th 2021, 26.2% of the world population has received at least one dose of a COVID-19 vaccine (1.04 billion), and one billion has been fully vaccinated, with very high vaccination rates in countries like Israel, Malta, and the UEA. Conversely, only 1% of people in low-income countries have received at least one dose with examples of vaccination frequency as low as 0.07% in the Democratic Republic of Congo. It is thus of paramount importance that more research on alternate methods to counter cell infection and propagation is undertaken that could be implemented in low-income countries. Moreover, an adjunctive therapeutic intervention would help to avoid disease exacerbation in high-rate vaccinated countries too. Based on experimental biochemical evidence on viral cell fusion and propagation, herein we identify (i) extracellular pH (epH), (ii) temperature, and (iii) humidity and osmolarity as critical factors. These factors are here in discussed along with their implications on mucus thick layer, proteases, abundance of sialic acid, vascular permeability and exudate/edema. Heated, humidified air containing sodium bicarbonate has long been used in the treatment of certain diseases, and here we argue that warm inhalation of sodium bicarbonate might successfully target these endpoints. Although we highlight the molecular/cellular basis and the signalling pathways to support this intervention, we underscore the need for clinical investigations to encourage further research and clinical trials. In addition, we think that such an approach is also important in light of the high mutation rate of this virus originating from a rapid increase.

International Society of Sports Nutrition position stand: sodium bicarbonate and exercise performance

Based on a comprehensive review and critical analysis of the literature regarding the effects of sodium bicarbonate supplementation on exercise performance, conducted by experts in the field and selected members of the International Society of Sports Nutrition (ISSN), the following conclusions represent the official Position of the Society: 1. Supplementation with sodium bicarbonate (doses from 0.2 to 0.5 g/kg) improves performance in muscular endurance activities, various combat sports, including boxing, judo, karate, taekwondo, and wrestling, and in high-intensity cycling, running, swimming, and rowing. The ergogenic effects of sodium bicarbonate are mostly established for exercise tasks of high-intensity that last between 30 s and 12 min. 2. Sodium bicarbonate improves performance in single- and multiple-bout exercise. 3. Sodium bicarbonate improves exercise performance in both men and women. 4. For single-dose supplementation protocols, 0.2 g/kg of sodium bicarbonate seems to be the minimum dose required to experience improvements in exercise performance. The optimal dose of sodium bicarbonate dose for ergogenic effects seems to be 0.3 g/kg. Higher doses (e.g., 0.4 or 0.5 g/kg) may not be required in single-dose supplementation protocols, because they do not provide additional benefits (compared with 0.3 g/kg) and are associated with a higher incidence and severity of adverse side-effects. 5. For single-dose supplementation protocols, the recommended timing of sodium bicarbonate ingestion is between 60 and 180 min before exercise or competition. 6. Multiple-day protocols of sodium bicarbonate supplementation can be effective in improving exercise performance. The duration of these protocols is generally between 3 and 7 days before the exercise test, and a total sodium bicarbonate dose of 0.4 or 0.5 g/kg per day produces ergogenic effects. The total daily dose is commonly divided into smaller doses, ingested at multiple points throughout the day (e.g., 0.1 to 0.2 g/kg of sodium bicarbonate consumed at breakfast, lunch, and dinner). The benefit of multiple-day protocols is that they could help reduce the risk of sodium bicarbonate-induced side-effects on the day of competition. 7. Long-term use of sodium bicarbonate (e.g., before every exercise training session) may enhance training adaptations, such as increased time to fatigue and power output. 8. The most common side-effects of sodium bicarbonate supplementation are bloating, nausea, vomiting, and abdominal pain. The incidence and severity of side-effects vary between and within individuals, but it is generally low. Nonetheless, these side-effects following sodium bicarbonate supplementation may negatively impact exercise performance. Ingesting sodium bicarbonate (i) in smaller doses (e.g., 0.2 g/kg or 0.3 g/kg), (ii) around 180 min before exercise or adjusting the timing according to individual responses to side-effects, (iii) alongside a high-carbohydrate meal, and (iv) in enteric-coated capsules are possible strategies to minimize the likelihood and severity of these side-effects. 9. Combining sodium bicarbonate with creatine or beta-alanine may produce additive effects on exercise performance. It is unclear whether combining sodium bicarbonate with caffeine or nitrates produces additive benefits. 10. Sodium bicarbonate improves exercise performance primarily due to a range of its physiological effects. Still, a portion of the ergogenic effect of sodium bicarbonate seems to be placebo-driven.

Skeletal muscle histidine-containing dipeptide contents are increased in freshwater turtles (C. picta bellii) with cold-acclimation

Freshwater turtles found in higher latitudes can experience extreme challenges to acid-base homeostasis while overwintering, due to a combination of cold temperatures along with the potential for environmental hypoxia. Histidine-containing dipeptides (HCDs; carnosine, anserine and balenine) may facilitate pH regulation in response to these challenges, through their role as pH buffers. We measured the HCD content of three tissues (liver, cardiac and skeletal muscle) from the anoxia-tolerant painted turtle (C. picta bellii) acclimated to either 3 or 20 °C. HCDs were detected in all tissues, with the highest content shown in the skeletal muscle. Turtles acclimated to 3 °C had more HCD in their skeletal muscle than those acclimated to 20 °C (carnosine = 20.8 ± 4.5 vs 12.5 ± 5.9 mmol·kg DM^-1; ES = 1.59 (95%CI: 0.16-3.00), P = 0.013). The higher HCD content shown in the skeletal muscle of the cold-acclimated turtles suggests a role in acid-base regulation in response to physiological challenges associated with living in the cold, with the increase possibly related to the temperature sensitivity of carnosine's dissociation constant.

Nonplacebo Controls to Determine the Magnitude of Ergogenic Interventions: A Systematic Review and Meta-analysis

INTRODUCTION

Placebos are used as a control treatment that is meant to be indistinguishable from the active intervention. However, where substantive placebo effects may occur, studies that do not include a nonplacebo control arm may underestimate the overall effect of the intervention (active plus placebo components). This study aimed to determine the relative magnitude of the placebo effect associated with nutritional supplements (caffeine and extracellular buffers) by meta-analyzing data from studies containing both placebo and nonplacebo control sessions.

METHODS

Bayesian multilevel meta-analysis models were used to estimate pooled effects and express the placebo effect as a percentage of the overall intervention effect.

RESULTS

Thirty-four studies were included, with the median pooled effect size (ES0.5) indicating a very small (ES0.5 = 0.09 (95% credible interval (CrI), 0.01-0.17)) improvement in the performance of placebo compared with control. There was no moderating effect of exercise type (capacity or performance), exercise duration, or training status. The comparison between active intervention and control indicated a small to medium effect (ES0.5 = 0.37 (95% CrI, 0.20-0.56)). Expressed in relative terms, the placebo effect was equivalent to 25% (75% CrI, 16%-35%) and 59% (75% CrI, 34%-94%) of the total intervention effect for buffers and caffeine.

CONCLUSIONS

These results demonstrate a very small but potentially important placebo effect with nutritional supplementation studies. A substantive proportion of supplement effects may be due to placebo effects, with the relative proportion influenced by the magnitude of the overall ergogenic effect. Where feasible, intervention studies should use nonplacebo control-arm comparators to identify the proportion of the effect estimated to come from placebo effects and avoid underestimating the overall benefits that the physiological plus psychobiological aspects associated with an intervention provide in the real world.

Translation, Cultural Adaptation, and Reproducibility of the Physical Activity Readiness Questionnaire for Everyone (PAR-Q+): The Brazilian Portuguese Version

Background: The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) is the international standard for pre-participation risk stratification and screening. In order to provide a practical and valid screening tool to facilitate safe engagement in physical activity and fitness assessments for the Brazilian population, this study aimed to translate, culturally adapt, and verify the reproducibility of the evidence-based PAR-Q+ to the Brazilian Portuguese language.

Method: Initially, the document was translated by two independent translators, before Brazilian experts in health and physical activity evaluated the translations and produced a common initial version. Next, two English native speakers, fluent in Brazilian Portuguese and accustomed to the local culture, back-translated the questionnaire. These back translations were assessed by the organization in charge of the PAR-Q+, then a final Brazilian version was approved. A total of 493 Brazilians between 5 and 93 yr (39.9 ± 25.4 yr), 59% female, with varying levels of health and physical activity, completed the questionnaire twice, in person or online, 1–2 weeks apart. Cronbach's alpha was used to calculate the internal consistency of all items of the questionnaire, and the Kappa statistic was used to assess the individual reproducibility of each item of the document. Additionally, the intraclass correlation coefficient and its 95% confidence interval (CI) were used to verify the general reproducibility (reliability) of the translated version.

Results: The Brazilian version had an excellent internal consistency (0.993), with an almost perfect agreement in 93.8% of the questions, and a substantial agreement in the other 6.2%. The translated version also had a good to excellent total reproducibility (0.901, 95% CI: 0.887–0.914).

Conclusion: The results show this translation is a valid and reliable screening tool, which may facilitate a larger number of Brazilians to start or increase physical activity participation in a safe manner.

Beta-alanine did not improve high-intensity performance throughout simulated road cycling

This study investigated the effect of beta-alanine supplementation on short-duration sprints and final 4-km simulated uphill cycling time-trial performance during a comprehensive and novel exercise protocol representative of the demands of road-race cycling, and determined if changes were related to increases in muscle carnosine content. Seventeen cyclists (age 38 ± 9 y, height 1.76 ± 0.07 m, body mass 71.4 ± 8.8 kg, V̇O_2max 52.4 ± 8.3 ml·kg^-1·min^-1) participated in this placebo-controlled, double-blind study. Cyclists undertook a prolonged intermittent cycling protocol lasting 125 min, with a 10-s sprint every 20 min, finishing with a 4-km time-trial at 5% simulated incline. Participants completed two familiarization sessions, and two main sessions, one pre-supplementation and one post-supplementation following 28 days of 6.4 g·day^-1 of beta-alanine (N=11) or placebo (N=6; maltodextrin). Muscle biopsies obtained pre- and post-supplementation were analysed for muscle carnosine content. There were no main effects on sprint performance throughout the intermittent cycling test (all P>0.05). There was no group (P=0.69), time (P=0.50) or group x time interaction (P=0.26) on time-to-complete the 4-km time-trial. Time-to-completion did not change from pre- to post-supplementation for BA (-19.2 ± 45.6 s, P=0.43) or PL (+2.8 ± 31.6 s, P=0.99). Beta-alanine supplementation increased muscle carnosine content from pre- to post-supplementation (+9.4 ± 4.0 mmol·kg^-1dm; P<0.0001) but was not related to performance changes (r=0.320, P=0.37). Chronic beta-alanine supplementation increased muscle carnosine content but did not improve short-duration sprint performance throughout simulated road race cycling, nor 4-km uphill time-trial performance conducted at the end of this cycling test.Highlights Performance during prolonged cycling events often depends on the ability to maintain an increased power output during higher intensity periods. Thus, cyclists are likely heavily dependent on their ability to resist fatigue during these periods of high-intensity activity.Meta-analytical data show beta-alanine to be an effective supplement to improve exercise outcomes, but little work exists on its efficacy during dynamic actions that are common during prolonged cycling.Beta-alanine supplementation increased muscle carnosine content but did not generate improvements in the performance of high-intensity cycling (10-s sprints or 4-km uphill time-trial) during a simulated road race cycling protocol.These data suggest that short duration sprints (≤10 s) and longer duration (>10 min) high-intensity activity throughout endurance cycling may not be improved with beta-alanine supplementation despite increases in muscle carnosine content.

Extracellular buffer choice influences acid-base responses and gastrointestinal symptoms

To compare the bicarbonate kinetics and gastrointestinal (GI) symptom responses between an equal dose of sodium bicarbonate and sodium citrate using delayed-release capsules. Thirteen active males (age 20.5 ± 2.1 y, height 1.8 ± 0.1 m and body mass [BM] 76.5 ± 9.6 kg) consumed either 0.3 g^.kg^-1 BM sodium bicarbonate, sodium citrate or a placebo, using a double-blind, randomized crossover design. Blood bicarbonate ion (HCO₃^-) concentration, pH and GI symptoms were measured pre-consumption and every 10 min for 180 min post-consumption. Blood HCO₃^- concentration (P < 0.001) and pH (P = 0.040) were significantly higher in the sodium bicarbonate condition compared with sodium citrate condition up to 3 h post-consumption. Peak blood HCO₃^- concentration was significantly higher with the sodium bicarbonate compared with citrate (P < 0.001). Mean GI symptom scores were lower (P = 0.037) for sodium citrate (1.5 ± 1.8 AU) than bicarbonate (2.6 ± 3.1 AU), with considerable inter-individual variability. No GI symptoms were reported following consumption of the placebo. Both substances increase HCO₃^- values significantly, with sodium bicarbonate causing significantly higher pH and HCO₃^- values than the same dose of sodium citrate, but results in slightly more severe GI symptoms.

Sodium bicarbonate supplementation and the female athlete: A brief commentary with small scale systematic review and meta-analysis

Sodium bicarbonate (SB) is considered an effective ergogenic supplement for improving high-intensity exercise capacity and performance, although recent data suggests that women may be less amenable to its ergogenic effects than men. Currently, an apparent paucity of data on women means no consensus exists on whether women benefit from SB supplementation. The aim of the current study was to quantify the proportion of the published literature on SB supplementation that includes women, and to synthesise the evidence regarding its effects on blood bicarbonate and exercise performance in women by performing a systematic review and meta-analysis. Electronic searches of the literature were undertaken using three databases (MEDLINE, Embase, SPORTDiscus) to identify relevant articles. All meta-analyses were performed within a Bayesian framework. A total of 149 SB articles were identified, 11 of which contained individual group data for women. Results indicated a pooled blood bicarbonate increase of 7.4 [95%CrI: 4.2-10.4 mmol·L^-1] following supplementation and a pooled standardised exercise effect size of 0.37 [95%CrI: -0.06-0.92]. The SB literature is skewed, with only 20% (30 studies) of studies employing female participants, of which only 11 studies (7.4%) provided group analyses exclusively in women. Despite the small amount of available data, results are consistent in showing that SB supplementation in women leads to large changes in blood bicarbonate and that there is strong evidence for a positive ergogenic effect on exercise performance that is likely to be small to medium in magnitude.Highlights This study aimed to quantify the proportion of the published literature on sodium bicarbonate supplementation that includes women and to synthesise the evidence regarding its ergogenic effect on women, using a systematic review and meta-analytic approach.The sodium bicarbonate literature is skewed, with only 30 studies (20%) employing female participants, of which only 11 studies (7.4%) provided group analyses exclusively in women.Despite the small amount of available data, results are consistent in showing that sodium bicarbonate supplementation in women leads to large changes in blood bicarbonate and that there is strong evidence for a positive ergogenic effect on exercise performance that is likely small to medium in magnitude.Based on these findings, we do not believe there is any evidence to support sex-specific sodium bicarbonate dosing recommendations and that current recommendations of 0.2-0.3 g·kg^-1BM of SB taken 60-180 min prior to high-intensity exercise appear appropriate for the female athlete.

Acute caffeine mouth rinsing does not improve 10-km running performance in CYP1A2 C-allele carriers

PURPOSE

This study assessed whether caffeine mouth rinsing affects 10-km run performance and vertical jump in recreational runners.

METHODS

A double-blind, placebo-controlled, crossover study was conducted. Ten well-trained volunteers performed two trials, following caffeine or placebo mouth rinse, separated by seven days. Immediately before the 10-km run, a 10-second mouth rinse with either 300 mg of caffeine (1.2%) or microcrystalline cellulose (placebo) diluted in 25 mL of water was performed. Pre- and post-exercise, participants performed a vertical jump test. A Garmin Forerunner® GPS, was used to measure 10-km running time and an 11-point Borg scale was used post-exercise to measure ratings of perceived exertion. Blood samples were also collected during the visit in the laboratory in the afternoon period to classify individuals according to their CYP1A2 genotype. Vertical jump performance was evaluated using a force plate.

RESULTS

Nine runners (90%) were CC homozygotes and one (10%) was an AC heterozygote for CYP1A2. There was no difference in 10-km time-trial performance (Placebo: 47.07 ± 5.18 vs. CAF: 47.45 ± 6.34 min, p = 0.89), ratings of perceived exertion (Placebo: 17 ± 1 vs. CAF: 16 ± 2, p = 0.34) or vertical jump power (Placebo, Pre: 4.5 ± 0.6 W•kg-1 and Post: 4.5 ± 0.7 W•kg-1; CAF: Pre: 4.4 ± 0.7 W•kg-1 and Post: 4.4 ± 0.8 W•kg-1, d = 0.21, p = 0.66) between trials.

CONCLUSION

Acute caffeine mouth rinsing (1.2%) did not improve 10-km performance and showed similar null effects on vertical jump performance in CYP1A2 C-allele carriers.

Capsule Size Alters the Timing of Metabolic Alkalosis Following Sodium Bicarbonate Supplementation

Introduction: Sodium bicarbonate (NaHCO₃) is a well-established nutritional ergogenic aid that is typically ingested as a beverage or consumed in gelatine capsules. While capsules may delay the release of NaHCO₃ and reduce gastrointestinal (GI) side effects compared with a beverage, it is currently unclear whether the capsule size may influence acid–base responses and GI symptoms following supplementation.

Aim: This study aims to determine the effects of NaHCO₃ supplementation, administered in capsules of different sizes, on acid–base responses, GI symptoms, and palatability.

Methods: Ten healthy male subjects (mean ± SD: age 20 ± 2 years; height 1.80 ± 0.09 m; weight 78.0 ± 11.9 kg) underwent three testing sessions whereby 0.3 g NaHCO₃/kg of body mass was consumed in either small (size 3), medium (size 0), or large (size 000) capsules. Capillary blood samples were procured pre-ingestion and every 10 min post-ingestion for 180 min. Blood samples were analyzed using a radiometer (Radiometer ABL800, Denmark) to determine blood bicarbonate concentration ([HCO3-]) and potential hydrogen (pH). GI symptoms were measured using a questionnaire at the same timepoints, whereas palatability was recorded pre-consumption.

Results: Capsule size had a significant effect on lag time (the time [HCO3-] changed, T_lag) and the timing of peak blood [HCO3-] (T_max). Bicarbonate T_lag was significantly higher in the large-sized (28 ± 4 min) compared with the small-sized (13 ± 2 min) capsules (P = 0.009). Similarly, T_max was significantly lower in the small capsule (94 ± 24 min) compared with both the medium-sized (141 ± 27 min; P < 0.001) and the large-sized (121 ± 29 min; P < 0.001) capsules. The GI symptom scores were similar for small-sized (3 ± 3 AU), medium-sized (5 ± 3 AU), and large-sized (3 ± 3 AU) capsules, with no significant difference between symptom scores (F = 1.3, P = 0.310). Similarly, capsule size had no effect on palatability (F = 0.8, P = 0.409), with similar scores between different capsule sizes.

Conclusion: Small capsule sizes led to quicker T_lag and T_max of blood [HCO3-] concentration compared to medium and large capsules, suggesting that individuals could supplement NaHCO₃ in smaller capsules if they aim to increase extracellular buffering capacity more quickly.

Is Individualization of Sodium Bicarbonate Ingestion Based on Time to Peak Necessary?

PURPOSE

To describe the reliability of blood bicarbonate pharmacokinetics in response to sodium bicarbonate (SB) supplementation across multiple occasions and assess, using putative thresholds, whether individual variation indicated a need for individualized ingestion timings.

METHODS

Thirteen men (age 27 ± 5 yr; body mass [BM], 77.4 ± 10.5 kg; height, 1.75 ± 0.06 m) ingested 0.3 g·kg BM SB in gelatine capsules on three occasions. One hour after a standardized meal, venous blood was obtained before and every 10 min after ingestion for 3 h, then every 20 min for a further hour. Time to peak (Tmax), absolute peak (Cmax), absolute peak change ([INCREMENT]Cmax), and area under the curve were analyzed using mixed models, intraclass correlation coefficient, coefficient of variation and typical error. Individual variation in pharmacokinetic responses was assessed using Bayesian simulation with multilevel models with random intercepts.

RESULTS

No significant differences between sessions were shown for blood bicarbonate regarding Cmax, [INCREMENT]Cmax or area under the curve (P > 0.05), although Tmax occurred earlier in SB2 (127 ± 36 min) than in SB1 (169 ± 54 min, P = 0.0088) and SB3 (159 ± 42 min, P = 0.05). Intraclass correlation coefficient, coefficient of variation, and typical error showed moderate to poor reliability. Bayesian modeling estimated that >80% of individuals from the population experience elevated blood bicarbonate levels above +5 mmol·L between 75 and 240 min after ingestion, and between 90 and 225 min above +6 mmol·L.

CONCLUSIONS

Assessing SB supplementation using discrete values showed only moderate reliability at the group level, and poor reliability at the individual level, whereas Tmax was not reproducible. However, when analyzed as modeled curves, a 0.3-g·kg BM dose was shown to create a long-lasting window of ergogenic potential, challenging the notion that SB ingestion individualized to time-to-peak is a necessary strategy, at least when SB is ingested in capsules.

Novel insights on caffeine supplementation, CYP1A2 genotype, physiological responses and exercise performance

Caffeine is a popular ergogenic aid due to its primary physiological effects that occur through antagonism of adenosine receptors in the central nervous system. This leads to a cascade of physiological reactions which increases focus and volition, and reduces perception of effort and pain, contributing to improved exercise performance. Substantial variability in the physiological and performance response to acute caffeine consumption is apparent, and a growing number of studies are implicating a single-nucleotide polymorphism in the CYP1A2 gene, responsible for caffeine metabolism, as a key factor that influences the acute responses to caffeine ingestion. However, existing literature regarding the influence of this polymorphism on the ergogenic effects of caffeine is controversial. Fast caffeine metabolisers (AA homozygotes) appear most likely to benefit from caffeine supplementation, although over half of studies showed no differences in the responses to caffeine between CYP1A2 genotypes, while others even showed either a possible advantage or disadvantage for C-allele carriers. Contrasting data are limited by weak study designs and small samples sizes, which did not allow separation of C-allele carriers into their sub-groups (AC and CC), and insufficient mechanistic evidence to elucidate findings. Mixed results prevent practical recommendations based upon genotype while genetic testing for CYP1A2 is also currently unwarranted. More mechanistic and applied research is required to elucidate how the CYP1A2 polymorphism might alter caffeine's ergogenic effect and the magnitude thereof, and whether CYP1A2 genotyping prior to caffeine supplementation is necessary.

Delegation by Allied Health Professionals to Allied Health Assistants: a mixed methods systematic review

BACKGROUND

Delegation by Allied Health Professionals (AHPs) to Allied Health Assistants (AHAs) was introduced in response to various challenges affecting modern health care delivery. However, the clinical and cost-effectiveness of using AHAs is relatively unexplored.

OBJECTIVES

The aim of this review was to synthesise the available evidence on; firstly, the clinical and cost-effectiveness of interventions delegated by AHPs to AHAs and secondly, AHPs', AHAs' and patients' attitudes and beliefs towards delegation.

DATA SOURCES

MEDLINE, AMED, CINAHL, Cochrane Library, PsycINFO, PEDro, OTseeker and Web of Science databases were searched from inception until January 2019 without restrictions.

STUDY SELECTION

Primary studies investigating the clinical and cost-effectiveness of any intervention delegated by an AHP, across the spectrum of clinical areas in relation to adult patients, as well as AHPs', AHAs' and patients' attitudes and beliefs about delegation.

DATA EXTRACTION & SYNTHESIS

Data were extracted by pairs of reviewers. Thematic analysis and synthesis of descriptive and analytical themes was conducted.

RESULTS

Thirteen publications of variable methodological quality were included. Three studies reported quantitative research and ten qualitative research. No study explored the cost-effectiveness. Only one study investigated clinical effectiveness. Training for both AHPs and AHAs and having clear processes in place were identified as important facilitators of delegation.

CONCLUSION AND IMPLICATIONS OF KEY FINDINGS

Delegation is not standardised across AHPs or within each profession. There are clear knowledge gaps regarding the clinical and cost-effectiveness of delegation by AHPs and patients' attitudes and preferences. Further research is needed to facilitate the standardisation of delegation.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019119557.

The Muscle Carnosine Response to Beta-Alanine Supplementation: A Systematic Review With Bayesian Individual and Aggregate Data E-Max Model and Meta-Analysis

Beta-alanine (BA) supplementation increases muscle carnosine content (MCarn), and has many proven, and purported, ergogenic, and therapeutic benefits. Currently, many questions on the nature of the MCarn response to supplementation are open, and the response to these has considerable potential to enhance the efficacy and application of this supplementation strategy. To address these questions, we conducted a systematic review with Bayesian-based meta-analysis of all published aggregate data using a dose response (Emax) model. Meta-regression was used to consider the influence of potential moderators (including dose, sex, age, baseline MCarn, and analysis method used) on the primary outcome. The protocol was designed according to PRISMA guidelines and a three-step screening strategy was undertaken to identify studies that measured the MCarn response to BA supplementation. Additionally, we conducted an original analysis of all available individual data on the MCarn response to BA supplementation from studies conducted within our lab (n = 99). The Emax model indicated that human skeletal muscle has large capacity for non-linear MCarn accumulation, and that commonly used BA supplementation protocols may not come close to saturating muscle carnosine content. Neither baseline values, nor sex, appeared to influence subsequent response to supplementation. Analysis of individual data indicated that MCarn is relatively stable in the absence of intervention, and effectually all participants respond to BA supplementation (99.3% response [95%CrI: 96.2–100]).

Translation and Validation of the Caffeine Expectancy Questionnaire in Brazil (CaffEQ-BR)

Caffeine is the world's most commonly used stimulant of the central nervous system. Caffeine is present in coffee and other beverages such as tea, soft drinks, and cocoa-based foods. The caffeine expectancy questionnaire was developed to investigate the effects of caffeine expectations and thus contribute to knowledge about its usage and subjective effects (response expectancies). This study aimed to evaluate caffeine expectation psychometrically in a sample of the Brazilian population. The original version of the "Caffeine Expectancy Questionnaire (CaffEQ)" was translated and validated into Brazilian-Portuguese and adapted to Brazilian culture to be used in the Brazilian adult (19-59 y) population. After the translation and back-translation processes of the original CaffEQ questionnaire, the content and semantic validation were performed by a group of experts. The Brazilian-Portuguese version of the questionnaire consists of 47 items, in seven factors, which assess subjective perceptions about the effects of caffeine. Interobserver reproducibility and internal consistency of the questionnaire were tested with a convenience sample (n = 50) of Brazilian adult consumers of caffeine sources, who completed the Brazilian CaffEQ (CaffEQ-BR) on two occasions separated by 24 h. All of the 47 questions were adequate regarding reliability, clarity, and comprehension. Psychometric properties could be replicated consistently. Appropriate internal consistency and validation were confirmed by Cronbach's alpha (α) 0.948, and an intraclass correlation coefficient of 0.976 was observed. The CaffEQ-BR was applied using a web-based platform to a convenience sample of Brazilian adults from all 27 Brazilian states (n = 4202 participants), along with measures of sociodemographic and caffeine consumption data. Factor validity was verified by confirmatory factor analysis. The seven factors presented a good fit for Root Mean Square Error of Approximation-RMSEA = 0.0332 (95% CI: 0.0290-0.0375). By confirming the validity and reliability of CaffEQ-BR, a useful tool is now available to assess caffeine expectations in the Brazilian adult population.