JournalTOCs School of Mathematical and Computer Sciences Heriot-Watt University Edinburgh, EH14 4AS, UK Email: journaltocs@hw.ac.uk Tel: +00 44 (0)131 4513762  Your IP address: 18.97.9.174 | ||||||
JournalTOCs School of Mathematical and Computer Sciences Heriot-Watt University Edinburgh, EH14 4AS, UK Email: journaltocs@hw.ac.uk Tel: +00 44 (0)131 4513762 Your IP address: 18.97.9.174 | ||||||
Hybrid journal (It can contain Open Access articles)
Objective: This project has 2 aims: First, to identify and summarize the most clinically important aspects of the published evidence on physical activity and sport in children and young people for the treatment or prevention of depression, anxiety, or symptoms of these conditions. Second, this study aims to funnel and develop this evidence to create clinically meaningful summaries on the Moving Medicine website and to guide clinicians on the day-to-day conversations clinicians have with children and young people about the benefits of physical activity for mental health.Design: This mixed methods study combines a scoping review with expert clinical review using the knowledge creation funnel component of the KTA framework.Data sources: We searched Pubmed, OvidSp, Cochrane, OvidEmbase, OvidEmcare and AMED databases using the following search strategy, which included appropriate truncation symbols to account for variations of the search terms and maximize searches: Depression OR depressed OR anxiety OR “generalised anxiety disorder” OR anxious* OR “low mood” OR “Mood disorder” AND Children OR Child OR adolescen* OR teenager OR “young people*” OR “young person*” AND Exercise OR “physical activ*” OR sport OR “Physically activ*”.Results: Sixty-eight studies were included in this review, and evidence suggested that interventions of varying intensity can reduce symptoms of depression and anxiety in children and young people. The effects of physical activity on other mental health outcomes were also encouraging. The available evidence suggests that physical activity is a promising strategy to improve mental health in children and young people.Conclusions: The literature overwhelmingly supports the benefits of regular physical activity both in the prevention of mental health issues for children and young people and in reduction of symptoms for those with already established symptoms. This review has translated this knowledge into accessible and relevant resources for healthcare professionals to use in their practice.
Objective: The exertional compartment syndrome (ECS) is often a delayed diagnosis. Compartment pressure measurements (CPM) confirm the diagnosis. Herein we present our algorithm for the evaluation and management (E&M) of ECS. It avoids multiple CPM and shows the importance of the history and examination for E&M of the ECS.Design: A literature review showed that limb abnormalities are hardly ever mentioned. Subsequently we show how the history, examination (for recognizing abnormalities), and CPM integrate with our algorithm for E&M of the ECS.Setting: Our algorithm evolved for a 32-year interval and approximately 150 ECS evaluations.Patients: Our E&M method was used for the above complement of patients.Interventions: The symptomatic muscle compartment(s) and the severity of pain during the inciting activity are ascertained. The examination detects abnormalities and tautness of muscle compartments. This information integrated into our ECS algorithm establishes which compartments need CPM.Main Outcome Measures: Pain severity is quantified on a 0- to 10-point scale. This information is integrated with history, examination findings, and CPMs to guide E&M for a range of ECS presentations.Results: Abnormalities detected on the examination often explain why ECS occurs. This information is valued by the patient, minimizes CPM, and offers sound advice for E&M.Conclusions: Our article heightens awareness of the ECS diagnosis for all levels of care providers. It objectifies pain severity, shows the importance of the examination, and minimizes ECM in giving advice to the referral sources.
Objective: The purpose of this systematic review is to evaluate the original peer-reviewed studies on athletes who developed myocarditis after coronavirus disease (COVID-19) infection or after COVID-19 mRNA vaccination. Both entities likely have an immunologic component. We discuss elite, professional, college, and adolescent athletes. The athletes are generally young and healthy, representing a distinctive population group that differs from the general population. This review includes diagnosis of myocarditis, incidence, complications, prognosis, and return-to-play guidance for sports medicine clinicians and coaches.Data Sources: We surveyed the PUBMED, Embase, and Web of Science databases for the relevant peer-reviewed articles in the English language published from the onset of the pandemic until April 2023. Included were original observational studies and case series. Excluded were individual case reports and a small series with incomplete data. The resulting search yielded 30 original articles.Main Results: Reported myocardial abnormalities in athletes were rare after COVID-19 infection and even less frequent after COVID-19 mRNA vaccination. True incidence, however, may be higher because of under-reporting and frequent asymptomatic presentation. Male gender was prevalent for both manifestations; postvaccination myocarditis occurrence was the highest after the second vaccine dose. Diagnostic and return-to-play algorithms were developed and should be adopted and followed.Conclusions: The risk of myocarditis from COVID-19 infection and COVID-19 mRNA vaccination is very low. The long-term prognosis and evolution of the observed cardiac magnetic resonance abnormalities are currently unknown. Although inferences can be made from the published data, COVID-19 and postvaccine myocarditis in athletes may represent only a small fraction of the true incidence of those who have been affected worldwide and not evaluated.
Abstract: We present a case of a professional basketball player who suffered from nonunion bilateral chronic tibial fractures, successfully treated with ultrasound-guided intraosseous injection with bone marrow aspirate concentrate. The patient was able to return to play full time after recovery from the procedure.
Objectives: The primary objective of this study was to analyze the correlation between the pain experienced at the time of a hamstring muscle injury and the hyperintense T2 weighted volume of the lesion measured on MRI. The secondary objectives were to analyze the differences in this pain with the lesion grade and the hamstring muscle head involved.Design: We performed a retrospective analysis of the data collected in a prospective, multicenter, noninterventional cohort study (HAMMER).Patients: A total of 61 patients were included in this analysis.Interventions: Patients with suspected hamstring muscle injury had an MRI after the injury.Main outcomes measures: They were evaluated for their pain intensity experienced at the time of injury with a Numeric Pain Rating Scale (NPRS) from 0 to 10.Results: There was a significant but weak correlation between the pain experienced at the time of hamstring muscle injury and the hyperintense T2 weighted volume (r = 0.287; P = 0.025). There were no significant differences in the pain according to the lesion grade (F(3,57) = 0.982; P = 0.408) nor according to the muscle involved (F(3,57) = 1.013; P = 0.394).Conclusions: Pain at the time of injury seemed to be weakly correlated with the extent of muscle lesion at medical imaging. Pain at the time of injury alone seems not enough to give us a clinical meaningful indication of the MRI hyperintense T2 weighted volume.
Objective: Sport-related concussion (SRC) affects cognitive and oculomotor function. We evaluated recovery from SRC in athletes with cognitive symptoms and/or oculomotor impairments who were prescribed early aerobic exercise treatment.Design: Secondary exploratory analysis of a randomized controlled trial.Setting: Outpatient sports medicine clinics.Participants: Male and female adolescents (13–18 years) within 10 days of SRC who were prescribed aerobic exercise and who reported either a low (
Objective: To examine the impact of the COVID-19 pandemic on the psychological health of key stakeholders within an elite UK sports organization.Design: The Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) was sent electronically to 500 employees, and 8 face-to-face interviews were conducted at an elite-level professional football club.Setting: English Premier League (EPL) Football Club.Participants: Office/stadium staff, coaching/backroom staff, players from the male U23, women's and men's senior teams.Independent Variables: Stakeholder groups that were invited to participate in the study: office/stadium staff, coaching/backroom staff, players from the U23, women's and men's senior teams, and variables of age and gender.Main Outcome Measure: WEMWBS scores across the office/stadium staff, coaching/backroom staff, and player cohort.Results: Of 122 responses (24% response rate) and 8 face–face interviews, the average WEMWBS score was 51.2 (SD ±8.4) and 14% of the cohort presented with scores suggestive of a higher risk of depression. The main findings were moderate effect size differences in WEMWBS scores with the players scoring higher than both the office/stadium staff (P = 0.01) and the coaching/backroom staff (P = 0.01).Conclusions: Office/stadium staff experienced greater compromising mental health effects from the COVID-19 pandemic, as compared with the coaching/backroom staff and players, respectively, suggesting that elite sports organizations should also consider providing mental health education and signposting strategies for this area of the workforce.
Objectives: To determine whether history of traumatic brain injury (TBI) is associated with psychopathology, and, in particular, substance use disorder (SUD) in young adults with a history of athletic participation.Design: Observational study.Setting: University in the northeastern United States.Participants: A large (n = 534) and mixed sex (57% female) sample of varsity and club sport athletes older than 18 years.Interventions: None.Main Outcome Measure: The Ohio State University Traumatic Brain Injury ID assessment and the Structured Clinical Interview for the diagnostic and statistical manual of mental disorders, fifth edition.Results: Twenty-five percent of participants reported no history of head injuries, 32% reported 1 head injury, and 43% reported more than 1 head injury. Thirty-eight percent of participants had been diagnosed with 1 or more concussions. Twenty-eight percent of participants had a current psychiatric diagnosis and 49% had at least 1 lifetime diagnosis. Head injuries and concussions were significantly associated with the presence of lifetime psychiatric diagnosis and symptoms or diagnosis of alcohol or SUD. More head injuries were associated with symptoms of post-traumatic stress disorder.Conclusions: Higher number of self-reported head injuries and diagnosed concussions were associated with a lifetime history of psychopathology, and specifically, with alcohol and substance use disorders. These relationships are similar to those seen in the general population of adults. The relationships also raise several interesting questions about recovery from head injuries in young adult athletes.
Objectives: The clinical consequences of coronavirus infection in elite judokas with exercise-induced bronchoconstriction (EIB) are unclear. We aimed to determine potential respiratory function abnormalities and recovery in athletes with and without EIB after severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection.Design: Retrospective cohort study.Setting: Türkiye Olympic Preparation Centre.Participants: This retrospective study analyzed data collected from 25 consecutive elite judokas diagnosed with and without EIB and SARS-CoV-2 infection, routinely followed at an Olympic Sports Center between September 2020 and 2021.Independent Variables: Respiratory muscle strength and pulmonary function data were collected before and up to 90 days after SARS-CoV-2 infection.Main Outcome Measures: Measurements included maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, and peak expiratory flow (PEF).Results: Infected athletes with EIB had more markedly reduced respiratory muscle strength and pulmonary function than those without EIB. Maximal inspiratory pressure was decreased by 14% and MEP by 8% from baseline in infected athletes with EIB during follow-up. Likewise, FEV1 and FVC decreased by 4%. Maximal inspiratory pressure, MEP, FEV1, and FVC remained abnormal after 90 days of SARS-CoV-2 infection in EIB athletes but normalized rapidly in non-EIB athletes. Peak expiratory flow seemed unaffected during follow-up. Exercise-induced bronchoconstriction severity was moderately correlated with the maximum fall in MEP during follow-up.Conclusions: Severe acute respiratory syndrome coronavirus-2 infection notably decreases respiratory muscle strength and pulmonary function in judokas, especially those with pre-existing EIB, thereby prolonging spontaneous recovery time.
Objective: The primary aim of this study was to examine sex differences in energy availability (EA) and its relationships with disordered eating, compulsive exercise, and body mass index (BMI) among adolescent athletes.Design: Cross-sectional study.Setting: University hospital pediatric sports medicine center.Participants: Sixty-four participants (61% female) of ages 13 to 18 years, actively participating in at least 1 organized sport.Main Independent Variable: Participant sex.Main Outcome Measures: Average 7-day EA (kcal/kg FFM/d; calculated using participant-recorded dietary intake and exercise expenditure from a wrist-worn heart rate/activity monitor), Eating Disorder Examination Questionnaire (EDE-Q) score (range 0–6), Compulsive Exercise Test (CET) score (range 0–25), and age- and sex-adjusted BMI percentile.Results: There were no significant sex differences in EA (females: 40.37 ± 12.17 kcal/kg FFM/d; males: 35.99 ± 12.43 kcal/kg FFM/d; P = 0.29), EDE-Q (females: 0.68 ± 0.70; males: 0.68 ± 0.83; P = 0.99), or CET scores (females: 11.07 ± 0.44; males: 10.73 ± 0.63; P = 0.66). There were low and insignificant negative correlations between EA and EDE-Q and CET scores for female athletes (EDE-Q: r = −0.22, P = 0.18; CET: r = −0.21, P = 0.09) and male athletes (EDE-Q: r = −0.09, P = 0.66; CET: r = −0.35, P = 0.08). EA and BMI-for-age percentile were inversely correlated in both male (r = −0.451, P = 0.009) and female (r = −0.37, P = 0.02) participants.Conclusions: In our sample of adolescent athletes, lower EA occurred in the absence of notable disordered eating or compulsive exercise behaviors, suggesting unintentional underfueling (and/or underreporting of energy intake), without significant sex differences. Low BMI can be an imperfect surrogate marker for low EA. These findings inform risk factors and screening practices for low EA among adolescent athletes.
Objective: To describe 3.0-Tesla (T) magnetic resonance imaging (MRI) findings of hamstring muscles in clinically recovered athletes who were cleared for return to play (RTP).Design: Prospective observational study.Setting: Hospital.Participants: Athletes (amateur and professional) who were cleared for RTP after hamstring injury. Fifty-eight participants were included in the analysis.Independent Variables: 3-T MRI at baseline (within 7 days from initial injury) and MRI at RTP (within 10 days of RTP).Main Outcome Measures: Injury location, grade of injury (modified Peetrons and British Athletics Muscle Injury Classification/BAMIC), presence and the extent of intramuscular signal abnormality, intramuscular tendon disruption, and thickness. Reinjuries within 1 year of RTP were recorded.Results: Magnetic resonance images at RTP showed that 55 (95%) participants had intramuscular increased signal intensity (edema) and 44 (76%) participants had intramuscular abnormal low-signal intensity (suggesting fibrosis) on MRI. There was an overall reduction of injury grades according to the modified Peetrons and BAMIC classification at initial injury to RTP. Three (5%) participants had no abnormal signal intensities (grade 0 or grade 0A) on MRI at RTP. Intramuscular tendon disruption, waviness, and tendon thickening were present at RTP in, respectively, 22 (38%), 15 (26%), and 36 (62%). We recorded 3 (5%) reinjuries.Conclusions: At RTP, 3.0-T MRI shows high percentages of MRI abnormalities (edema, fibrosis, and intramuscular tendon disruption and thickening). We conclude that complete normalization of 3.0-T MRI is not expected for RTP decision after a hamstring injury. Its possible association with reinjury risk has to be determined in larger cohorts.
Objective: To evaluate the effect of the Nordic hamstring exercise on normalized muscle activity and relative contribution of the biceps femoris long head, semitendinosus, and semimembranosus through multichannel electromyography in the late-swing phase of high-speed running.Design: A pragmatic, 2-arm, single-center randomized controlled trial. Participants were randomly assigned to a Nordic group or control group.Setting: Dutch male basketball.Participants: Twenty injury-free players (mean age 18 ± 3 years).Intervention: A 12-week Nordic hamstring exercise intervention.Main Outcome Measures: Level of normalized muscle activity (percentage maximal voluntary isometric contraction [%MVIC]) and relative contribution (%con) of hamstring muscles for 12 weeks.Results: The Nordic hamstring exercise intervention did not result in significant changes for 12 weeks. For normalized muscle activity, between-group differences (compared with the control group) for 12 weeks were 11.4 %MVIC (95% confidence interval [95% CI]: −11.0, 33.8) for the biceps femoris long head, −9.4 %MVIC (95% CI: −23.3, 5.2) for the semitendinosus, and −2.7 %MVIC (95% CI: −15.8, 10.3) for the semimembranosus, P = 0.151. For relative contribution, between-group differences for 12 weeks were −6.1 %con (95% CI: −2.4, 14.6) for the biceps femoris long head, −7.0 %con (95% CI: −13.6, −0.4) for the semitendinosus, and 0.9 %con (95% CI: −9.2, 11.0) for the semimembranosus P = 0.187. Positive values are in favor of the Nordic group.Conclusions: A 12-week Nordic hamstring exercise intervention did not affect the level of muscle activity and relative contribution of hamstring muscles in the late-swing phase of high-speed running. Because of the low amount of data sets, results should be interpreted cautiously.
Abstract: Significant intraventricular gradient development during exercise is rare, usually occurring with left ventricular hypertrophy. The etiopathogenesis consists of the increase in nonobstructive physiological gradients; ventricular cavitary obliteration with consequent end-systolic obstruction; and midsystolic obstruction caused by systolic anterior movement of the mitral valve compromising flow. A correlation between intraventricular gradient development and various symptoms has been established. Chest pain is common in children and is a frequent reason for referral to pediatric cardiologists. Despite the benign nature of most pediatric chest pain, extensive and costly cardiac evaluation is common in these patients. In the case presented here, we describe an adolescent rowing athlete with excruciating effort angina only during upright exercise, which was replicated while performing an exercise stress echocardiography.
Objective: To compare physical contacts (PCs), including head contacts (HCs), suspected concussion, and nonconcussion injury incidence rates between youth ringette and female ice hockey.Design: Cross-sectional.Setting: Alberta ice arenas.Participants: Players participating in 8 U16AA (ages 14-15 years) ringette and 8 U15AA (ages 13-14 years) female ice hockey games during the 2021 to 2022 season.Assessment of Risk Factors: Dartfish video-analysis software was used to analyze video recordings.Main Outcome Measures: Univariate Poisson regression analyses (adjusted for cluster by team-game, offset by game minutes) were used to estimate PCs (including HCs) and suspected injury (concussion and nonconcussion) and concussion-specific IRs and incidence rate ratios (IRRs) to compare sports. Proportions of all PCs that were body checks (level 4-5 trunk PC) and direct HCs (HC1) penalized were reported.Results: Ringette had a 2.6-fold higher rate of body checking compared with hockey (IRR = 2.63, 95% CI: 1.59-4.37). Ringette also had a 2-fold higher rate of HC1 compared with hockey (IRR = 2.08, 95% CI: 1.37-3.16). A 3.4-fold higher rate of suspected injury was found in ringette (IRR = 3.37, 95% CI: 1.40-8.15). There was no significant difference in suspected concussion IRs in ringette compared with hockey (IRR = 1.93, 95% CI: 0.43-8.74). Despite being prohibited in both sports, only a small proportion of body checks (Ringette = 18%; Hockey = 17%) and HC1 (Ringette = 6%; Hockey = 6%) were penalized.Conclusions: Higher rates of body checking, HC1, and suspected injuries were found in ringette compared with female ice hockey. Body checking and HC1 were rarely penalized, despite rules disallowing them in both sports. Future research should consider other youth age groups.
Objective: To evaluate the trabecular bone score (TBS) Z scores in long-distance runners with bone stress injuries (BSIs) in whom the bone mineral density (BMD) Z score is more than −1.0 (Aim 1) and whether the number of runners with abnormal TBS Z scores would be higher in those with BSI in trabecular-rich sites as compared with cortical-rich sites (Aim 2).Design: Retrospective cohort study.Setting: Institutional sports medicine center.Patients: We analyzed Z scores derived from the TBS and BMD in 44 long-distance runners aged 18 to 40 years who had sustained BSIs between 2017 and 2023 and undergone a dual-energy x-ray absorptiometry scan with reported TBS measurements within 1 year before or 2 years after their injuries.Independent Variables: Bone mineral density and TBS Z scores.Main Outcome Measures: Evaluation of BMD and TBS Z scores in long-distance runners with BSIs, further stratified according to cortical-rich and trabecular-rich BSIs.Results: Bone mineral density assessments revealed an average Z score of −0.96 ± 0.99. In this cohort of 44 runners, 55% (n = 24) of runners were reported to have BMD Z score more than −1.0. Within this subgroup, 54% (n = 13) displayed abnormal TBS. Stratifying BSIs by trabecular- (n = 23) and cortical-rich (n = 19) sites, we found no significant difference in sex, mean BMD, or the number of runners with abnormal TBS between the 2 groups.Conclusions: Trabecular bone score Z scores in sports medicine may provide complementary information to BMD in long-distance runners with BSI, particularly when the BMD Z scores are more than −1.0. However, further research is needed to validate the usefulness of TBS Z scores in this context.Study Design: Cohort study.Level of Evidence: Retrospective Case Series, IV.
Objective: Despite excellent functional outcomes after shoulder stabilization surgery, a substantial number of patients fail to return to sports (RTS) at the preinjury level. The psychological factors affecting RTS postsurgery have been underexplored. This scoping review aimed to identify and analyze potential psychological factors influencing the decision to RTS after shoulder stabilization surgery.Data Sources: We reviewed the EBSCOhost/SPORTDiscus, PubMed/Medline, Scopus, EMBASE, and Cochrane Library databases for studies on patients with anterior glenohumeral instability who underwent stabilization surgery. We included studies that reported on RTS and considered the psychological factors influencing the decision to return.Main Results: Our analysis comprised 21 articles involving 2073 patients. Psychological factors influencing RTS after surgery were categorized within the framework of transactional stress and coping model. Primary appraisal factors, such as fear of reinjury, kinesiophobia, and anxiety, emerged as significant influencers. In addition, we explored factors related to social support, self-determination, motivation, competing interests, and advanced age. Assessment tools were used to evaluate the psychological readiness for RTS.Conclusions: This scoping review identified fear of reinjury and kinesiophobia as important psychological barriers to returning to sports after shoulder stabilization surgery. The limited use of psychological assessment tools and lack of comparative studies have restricted robust conclusions.Level of Evidence: Level IV, Scoping review.
Objective: To determine how football head impacts are influenced by self-efficacy (SE), helmetless tackling intervention participation (IP), and years of experience (YE) playing football.Design: Cross-sectional.Setting: Three high schools.Participants: 120 (male; n = 118, female; n = 2, 15.57 ± 1.23 years) participants were recruited from 5 high school teams (3 varsity and 2 junior-varsity).Independent Variables: SE, days of IP, and YE playing tackle football.Main Outcome Measures: SE was measured using a 53-question survey and categorized into 5 subscales. The accumulation of total head impacts (THI) was measured using Riddell InSite Speedflex helmets (Elyria, OH) throughout the season. Head impact exposure (HIE) was standardized as a ratio of impacts per session (games, scrimmages, and practices). Multiple regression analyses tested the relationship between THI or HIE with the predictor variables.Results: For THI, 22.1% was explained by the predictors (r = 0.470, r2 = 0.221). Intervention participation had a negative correlation (B = −4.480, P = 0.019), whereas confidence in performing proper tackling and blocking (SE1) (B = 3.133, P = 0.010) and>8 YE (B = 135.9, P = 0.009) positively correlated with THI. For HIE, 25.4% was explained by the predictors (r = 0.504, r2 = 0.254). Intervention participation negatively correlated (B = −0.077, P = 0.007), whereas SE1 (B = 3.133, P = 0.010) and>8 YE (B = 2.735, P ≤ 0.001) correlated positively with HIE.Conclusions: Increased head impacts were associated with less helmetless tackling participation, more than 8 YE, and more self-confidence in tackling ability. Increasing the amount of time athletes spend practicing proper tackling and blocking techniques to reduce head first and risky play is warranted to reduce the amount of head impacts received over time.
Objective: COVID-19 has been associated with myocardial involvement in collegiate athletes. The first report from the Big Ten COVID-19 Cardiac Registry (Registry) was an ecological study that reported myocarditis in 37 of 1597 athletes (2.3%) based on local clinical diagnosis. Our objective was to assess the relationship between athlete and clinical characteristics and myocardial involvement.Design: Cross-sectional study.Setting: We analyzed data from 1218 COVID-19 positive Big Ten collegiate athletes who provided informed consent to participate in the Registry.Participants: 1218 athletes with a COVID-19–positive PCR test before June 1, 2021.Assessment of Independent Variables: Demographic and clinical characteristics of athletes were obtained from the medical record.Main Outcome Measures: Myocardial involvement was diagnosed based on local clinical, cardiac magnetic resonance (CMR), electrocardiography, troponin assay, and echocardiography. We assessed the association of clinical factors with myocardial involvement using logistic regression and estimated the area under the receiver operating characteristic (ROC) curve.Results: 25 of 1218 (2.0%) athletes met criteria for myocardial involvement. The logistic regression model used to predict myocardial involvement contained indicator variables for chest pain, new exercise intolerance, abnormal echocardiogram (echo), and abnormal troponin. The area under the ROC curve for these indicators was 0.714. The presence of any of these 4 factors in a collegiate athlete who tested positive for COVID-19 would capture 55.6% of cases. Among noncases without missing data, 86.9% would not be flagged for possible myocardial involvement.Conclusion: Myocardial involvement was infrequent. We predicted case status with good specificity but deficient sensitivity. A diagnostic approach for myocardial involvement based exclusively on symptoms would be less sensitive than one based on symptoms, echo, and troponin level evaluations. Abnormality of any of these evaluations would be an indication for CMR.
