Worldwide, there is a large and growing group of older adults. Frailty is known as an important discriminatory factor for poor outcomes. The Clinical Frailty Scale (CFS) has become a frequently used frailty instrument in different clinical settings and health care sectors, and it has shown good predictive validity. The aims of this study were to describe and validate the translation and cultural adaptation of the CFS into Swedish (CFS-SWE), and to test the inter-rater reliability (IRR) for registered nurses using the CFS-SWE.An observational study design was employed. The ISPOR principles were used for the translation, linguistic validation and cultural adaptation of the scale. To test the IRR, 12 participants were asked to rate 10 clinical case vignettes using the CFS-SWE. The IRR was assessed using intraclass correlation and Krippendorff’s alpha agreement coefficient test.The Clinical Frailty Scale was translated and culturally adapted into Swedish and is presented in its final form. The IRR for all raters, measured by an intraclass correlation test, resulted in an absolute agreement value among the raters of 0.969 (95% CI: 0.929–0.991) and a consistency value of 0.979 (95% CI: 0.953–0.994), which indicates excellent reliability. Krippendorff’s alpha agreement coefficient for all raters was 0.969 (95% CI: 0.917–0.988), indicating near-perfect agreement. The sensitivity of the reliability was examined by separately testing the IRR of the group of specialised registered nurses and non-specialised registered nurses respectively, with consistent and similar results.The Clinical Frailty Scale was translated, linguistically validated and culturally adapted into Swedish following a well-established standard technique. The IRR was excellent, judged by two established, separately used, reliability tests. The reliability test results did not differ between non-specialised and specialised registered nurses. However, the use of case vignettes might reduce the generalisability of the reliability findings to real-life settings. The CFS has the potential to be a common reference tool, especially when older adults are treated and rehabilitated in different care sectors.The online version contains supplementary material available at 10.1186/s12877-023-04525-6. Worldwide, there is a large and growing group of older adults, including patients with complex needs. Frailty is known as an important discriminatory factor for poor outcomes, such as increased dependence, recurrent hospitalisation and death –5. ThereThe accumulated deficit model is based on the observation that most health risks increase with age and, when a person has more deficits than others of the same age, frailty emerges. A Frailty Index (FI) encompassing 70 different clinical deficits   constituIt is important to understand the purpose of the measurement , 11. TheThere is no gold standard when it comes to which instrument to use when evaluating frailty in clinical practice. Instead, there are different tools, corresponding to one or more purposes , 11, 18.The CFS has become a frequently used frailty instrument in different clinical settings and health care sectors and it has shown good predictive validity regarding multiple outcomes –24. In tvulnerable, marks the point at which most people begin to need help. Steps 5 to 8 describe states of progressively increasing frailty and, finally, the ninth step applies to those who are in a state of terminal illness, with short expected survival, but no other signs of frailty. There is a short descriptive text and, optionally, a pictogram associated with each step, in order to facilitate the assessment process and there is also guidance on estimating frailty in older adults with dementia.The CFS-9 1.2 is a scale, on which the first three steps denote different grades of fitness and does not include frailty. The fourth step, In 2020, the CFS-9 was further revised (version 2.0) with minor edits to the level descriptions and their corresponding labels. CFS label 2 changed from “Well” to “Fit”, level 4 from “Vulnerable” to “Living with very mild frailty” and levels 5–8 were restated as “Living with…” mild, moderate, severe and very severe frailty, respectively. The differences between CFS 1.2 and 2.0 can be regarded as be minor , 25. ImpThe CFS-7 was translated into Swedish in 2009 , followeThe aim of this study was first to translate and culturally adapt the CFS into Swedish (CFS-SWE), describing the translation and linguistic validation process, and second to test the inter-rater reliability for registered nurses using the CFS-SWE.One of the authors (NE) was asked to take responsibility for the translation process by the CFS copyright holder and instrument developer . The trapreparation, included the initial work before the translation process could start. Relevant co-workers were recruited and a multidisciplinary taskforce was set up. The taskforce consisted of a physician, an RN, a physiotherapist, and an occupational therapist, all of whom had long clinical experience and research merits. A reference group comprising experienced clinicians and researchers in related disciplines and appropriate and experienced expert translators were identified and recruited. Prior to the translation, the process and methodological issues were carefully considered and planned and a brief review of the background to the scale was made, including re-reading and reflection on relevant references [The first step, ferences , 19, preferences , 26 and ferences , 29 instforward translation and reconciliation included the translation of the English version of CFS-2.0 (source) into Swedish (target language), by two different professional translation agencies. After that, these two versions were compared and merged into one single Swedish translation by the task force. The next step was back translation by a professional translator, in which the above-mentioned merged Swedish translation was translated back to English (back-translated English version).The ISPOR process then continued with The back-translation review implied that the taskforce compared the back-translated English version of the instrument with the original to highlight and reflect on discrepancies between them. The harmonisation step included discussions to achieve a consistent approach to translation problems. After that, the updated Swedish version was tested on relevant reference persons to consider alternative wording and to check understandability, interpretation and cultural relevance, mentioned as the cognitive debriefing and review of the cognitive debriefing step. The task force then reflected on these comments in relation to the original English version to highlight and amend discrepancies. The ISPOR process ended with proofreading of the final version, to correct any typographical, grammatical, or other errors, and a final report was written.An estimation of the appropriate numbers of cases and raters in the reliability analyses was made, pragmatically, based on advice from a senior statistician and previously reported reliability tests in similar contexts , 29, 31.Ten case vignettes were produced by two of the authors . The case vignettes were built to imitate real-word patients, with influence from ten anonymised cases judged as clinically relevant, and they were selected collectively to represent all nine levels of the CFS. The case vignettes were pragmatically validated by senior clinicians  with regard to content and CFS grading. The cases provided information on symptoms of disease, diagnoses, dependence on others, cognitive function and the physical status of the patients, see Additional File The selection of raters was made to identify a sample of study raters, representative of raters handling patients in real-world practice. Since the majority of the CFS grading in a Swedish health care context is undertaken by registered nurses (RNs), the authors recruited twelve raters as a convenience sample from the authors’ network of RNs in the cities of Stockholm, Linköping and Trollhättan . Clinically working RNs, speaking the Swedish language, who accepted participation in the study, were included. Exclusion criteria: other professions than RN, retired RNs, not speaking the Swedish language.Our study included RNs from different parts of Sweden with experience from both the primary and secondary health care sectors. Moreover, they represented a wide range of length of clinical experience. Half the raters had previous experience of CFS grading (ranging from one grading a week to one grading every six months). Six of the raters were specialised RNs, while six were non-specialised.The raters participated voluntarily in the study and their scores were treated confidentially. Two weeks prior to the reliability testing, all the raters were introduced to frailty as a concept, the CFS-9 and how CFS grading should be undertaken. This was done by two experienced raters  in a one-hour digital education course.The raters individually assessed each case in written form according to the nine-point CFS-SWE. The cases were presented in random order of severity, i.e. CFS grade, but they were rated in the same order by each rater. The written answers were sent to and treated confidentially by the authors. The raters had the opportunity to obtain additional information on how to grade CFS from a manual on the SWEDEHEART homepage .An observational study design was employed. We have completed the checklists according to the The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)  and the https://eisp.liu.se/isp/index Analyses of the inter-rater reliability (IRR) associated with the CFS were made using the intraclass correlation (ICC) test [A data analysis and research plan was registered in the web-based electronic individual study plan for one of the authors (HO) at Linköping University. CC) test , 37 and CC) test , both wiCC) test . The levCC) test .The sensitivity of the reliability was examined by separately testing the IRR of the group of specialised RNs and non-specialised RNs respectively.p < 0.05.Statistical analysis was performed using SAS software. The statistical significance threshold for all tests was set at final report in Additional File preparation, forward translation and reconciliation, a high level of agreement in the meaning and wording of the two forward translations was observed. Minor differences were resolved in a reconciliation meeting. The back translation step corresponded satisfactorily with the reconciled forward translation. In the back-translation review and harmonisation step the task force compared the back-translated English version of the instrument with the English original version. They highlighted and reflected on smaller discrepancies and revised to achieve a consistent approach to translation problems. The steps of cognitive debriefing and review of the cognitive debriefing indicated good understandability and cultural relevance. In the proofreading step, some minor grammatical errors were corrected, Additional File final report.The translation and linguistic validation process is shown in Additional File All 12 raters were RNs and they assessed the 10 cases, yielding 120 observations. The included RNs had a variety of clinical experience from the primary and secondary health care sectors and their length of clinical experience ranged from three to 30 years (median 11.5 yrs). Six of the raters had previous experience of CFS grading (ranging from one grading a week to one grading every six months). Six of the raters were specialised RNs and six of the raters were non-specialised RNs.The IRR for all raters  measured by an ICC test resulted in an absolute agreement value among the raters of 0.969 (95% CI: 0.929–0.991), and a consistency value of 0.979 (95% CI: 0.953–0.994), which indicates excellent reliability. The Krippendorff’s alpha agreement coefficient for all raters was 0.969 (95% CI: 0.917–0.988), indicating near-perfect agreement.The IRR for non-specialised RNs measured by an ICC test resulted in an absolute agreement value among the raters of 0.948 (95% CI: 0.866–0.985) and a consistency value of 0.969 (95% CI: 0.927–0.991). The Krippendorff’s alpha agreement coefficient for non-specialised RNs was 0.948 (95% CI: 0.857–0.982).The IRR for specialised RNs measured by an ICC test resulted in an absolute agreement value among the raters of 0.987 (95% CI: 0.970–0.996) and a consistency value of 0.988 (95% CI: 0.927–0.997). The Krippendorff’s alpha agreement coefficient for non-specialised RNs was 0.987 (95% CI: 0.952–0.997).We systematically translated and validated the CFS into Swedish (CFS-SWE). The translation and linguistic validation was undertaken using the established and recommended ISPOR technique. The translation work was carried out by individuals representing different professions, in order appropriately to address the multidisciplinary components of the CFS. Our analyses showed that the inter-rater reliability for all raters  was excellent, according both to the intraclass correlation test and to the Krippendorff’s alpha agreement coefficient test. The reliability test results did not differ between non-specialised and specialised RNs.These findings agree with the results of translations of previous versions (CFS-7 and CFS-9 1.2 respectively) of the CFS into Swedish , 26. SimThe large majority of the CFS gradings in a Swedish health-care context are undertaken by RNs. Our study included RNs from different parts of Sweden with experience from both the primary and secondary health care sectors. Moreover, they represented a wide range of length of clinical experience. Half the raters had previous experience of CFS grading (ranging from one grading a week to one grading every six months). Six of the raters were specialised RNs, while six were non-specialised. We believe that the characteristics of the selected sample of study raters were reasonably representative of CFS-raters handling patients in real-world practice, which indicates good generalisability. This is important, as the assessment according to the CFS is under continuous dispersion in Swedish healthcare, e.g. in the SWEDEHEART and intensive care registries, as well as in clinical practice.These findings indicate that the CFS-SWE is a reliable and useful measurement of frailty that can be applied and carefully spread in both the primary and secondary health care sectors. This conclusion agrees with the results in previous studies of the translation of the CFS into other languages , 29, 31.A frailty assessment is recommended in different guidelines, both geriatric and non-geriatric, e.g. regarding cardiovascular care , 18, 44.In spite of the results of our study, reliability evaluations should be interpreted with caution as they are dependent on assessment conditions . Other pThis study has several strengths. First, the translation and linguistic validation was completed using a rigorous procedure that followed the ISPOR guidelines. This is important, as quality depends on the chosen methodology and poorly translated instruments threaten the validity of the data . Second,Our study has some limitations. First, case vignettes could be regarded as hypothetical and they might be associated with a risk of bias and inflated inter-rater reliability which has been mentioned in previous studies with similar purpose, e.g. . On the n = 10). However, the cases were designed to encompass all the CFS levels, presented in random order of severity, and they had been pragmatically validated by senior raters. Overall, a comparison between studies on the reliability of CFS rating based on clinical case vignettes .Additional file 2. The translation process.Additional file 3. Final report on the translation process. Additional file 4. GRRAS checklist.Additional file 5. STROBE checklist.


Brucella strains. In this study, classical bio-typing assay, multilocus variable-number tandem repeat analysis, and the whole-genome sequencing–single-nucleotide polymorphism approach were used to illustrate the epidemiological and evolutionary patterns of Brucella melitensis. A total of 54 B. melitensis bv. 3 strains were isolated and molecularly characterized, with all strains belonging to the East Mediterranean lineages. Cross-regional transmission events  were caused by common sources of infection, suggesting that predominant circulating genotypes are endemic in different regions. Strengthening surveillance in animal brucellosis and controlling infected animals’ cross-border movement are necessary. Two strains isolated from humans and marmots were clustered in the same sub-clade, implying the possible existence of direct and/or indirect contact between sheep (and goats) and wildlife (marmots), but this needs to be verified by further investigations. The global-scale phylogenetic analysis indicated that 54 strains sorted into six subclades, four of which formed independent lineages, suggesting that the increase in the incidence rate of human brucellosis may be caused by local circulating lineages. Further strengthening the serology and pathogen surveillance of animals (wildlife) and humans will contribute to an in-depth understanding of the transmission chain of human brucellosis in this region.Since 2010, the cases and incidences of human brucellosis have been increasing annually in Qinghai (QH) Province. Molecular epidemiology and phylogenetic analyses of strains from this region are crucial to better understand the transmission of the disease and the evolutionary patterns of  Micrococcus melitensis) in 1887  is a globally distributed zoonotic disease. It has severe adverse effects on public health and the agriculture field, including population, livestock, and wildlife health. Since David Bruce first isolated the organism  Province is located in northwestern China, and animal farming is the main source of income for the local population. Because of low development levels, poverty, and poor hygiene conditions, animal and human brucellosis is highly prevalent in this region . Althoug to 2019 . Since 2 to 2019 . General strains . Further strains . ImportaB. melitensis strains were isolated and identified in the present study, of which 52 were recovered from humans, one from the liver of an aborted sheep fetus, and one from a marmot. All of the tested strains were isolated and identified according to the standard Brucella spp. bio-typing procedures  was used to yield sequencing libraries according to the manufacturer’s specifications, as follows: the quality-tested extracted DNA was fragmented using the E210 Covaris instrument , and segments with approximately 350 bp in length were selected in a 3% agarose gel. The selected DNA fragments were then end-repaired, A-tailed, and ligated to Illumina-compatible adaptors  and then PCR-amplified using Illumina adapter-specific primers and Platinum Pfx DNA polymerase (Invitrogen), and the paired-end sequencing library was completed. Then, the draft genomic sequence of 54 strains was determined, and SOAPdenovo software v.2.04 (The genome sequencing strategy of strains was referenced in a previous study . Brieflye v.2.04  was usedB. melitensis strains was performed as previously reported (B. melitensis 16 M (Chromosome accession numbers: NC_003317.1 and NC_003318.1) was used as the reference genome  was identified as ST 68 , 63 (n = 2), 114 (n = 2), and 118 (n = 1), whereas six MLVA-11 genotypes were found, that is, four known  and two newly identified (N1 (n = 3) and N2 (n = 1)), which are all single-locus variants to MLVA-11 genotype 116. These data indicated that all strains belonged to the Eastern Mediterranean lineage , 2020 (n = 4), and 2021 (n = 9), implying that a major genotype is endemic in these regions, and indicating a lack of control over the spread of this disease between regions. Moreover, XHM53 from GT7 was obtained from the liver of an aborted sheep fetus, and two strains (XHM7 and XHM62) in this shared genotype GT7 were isolated from a couple (husband and wife). Another two strains (XHM42 and XHM44) from the shared genotype GT19 were obtained from a family (father and son) who had a contact history with aborted lambs. These data suggest that each infection event was caused by a common source of infection. The remaining 23 genotypes were all singular, and each represented only one strain , of which eight genotypes  were each shared by at least two strains . GT7 hade strain , suggeste strain .B. melitensis lineages were circulating in QH, causing the cross-regional human brucellosis epidemic.All 54 strains were divided into two clusters (I and II) based on the WGS-SNP phylogeny analysis (namely CI and CII), and CII was further sorted into five sub-clusters (CII SC1-5) . FurtherB. melitensis was performed. The total number of SNPs found in all 132 B. melitensis strains ranged from 289 to 2,038  were used to characterize the  gazelle . These dal hosts . Sheep aand deer . Thus, bB. melitensis strains belong to the East Mediterranean group, which comprises strains from Europe, the Middle East, and Asia  and 116 (MLVA-11) are predominant genotypes, accounting for 90.7% (49/54) and 81.5% (44/54), respectively. These data indicated that all strains were of Eastern Mediterranean lineage. With the use of MLVA-8, the majority of strains (84/105) were genotyped, and 42 were clustered into the East Mediterranean lineages . Furtherand Asia . MLVA geand Asia . Further regions . We hypo regions  because  regions . The pur regions . TherefoBrucella strains  can be found in the article/The research protocol was reviewed and approved by the Ethics Committees of the Institute for Endemic Disease Control and Prevention of Qinghai (No. 2022006). Informed consent was obtained from all patients. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. The animal study was approved by the Ethics Committees of the Institute for Endemic Disease Control and Prevention of Qinghai (No. 2022006). Informed consent was obtained from all patients. The study was conducted in accordance with the local legislation and institutional requirements.HX performed the strain isolation, collection, and epidemiology data process. ZhiL and ZheL participated in the design of the study, analyzed the sequencing data, and drafted the manuscript. ZZ, JW, LM, JL, XY, and LR participated in the field epidemiology survey. ZhiL, ZheL, and LX critically reviewed the manuscript and managed the project. All authors contributed to the article and approved the submitted version.This work was supported by the National Natural Science Foundation of Qinghai, China (No. 81860588). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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Per- and polyfluoroalkyl substances (PFASs) are highly fluorinated organic compounds that have been widely used in industry during the past few decades. The main exposure routes for PFASs are thought to be the diet, drinking water, and dust. In this study, we aimed to evaluate the relationship between perfluoroalkyl carboxylic acids  and the plasma eicosapentaenoic acid-to-arachidonic acid ratio (EPA/AA), a biological indicator of seafood intake, to determine whether seafood intake may represent a means of exposure to PFASs in the Japanese population.We performed a cross-sectional study using 131 plasma samples collected from residents of Kyoto, Japan in 2013 and held in the Kyoto University biological sample bank. The concentrations of perfluoroheptanoic acid (PFHpA), perfluorooctanoic acid (PFOA), perfluorononanoic acid (PFNA), perfluoroundecanoic acid (PFDA), perfluoroundecanoic acid (PFUnDA), perfluorododecanoic acid (PFDoDA), perfluorotridecanoic acid (PFTrDA), EPA, and AA were quantified by gas chromatography-mass spectrometry, and multiple linear regression was used to analyze the results.p = 0.0005); PFHpA showed a significant negative linear association with estimated glomerular filtration rate ; and PFHpA, PFOA, PFNA, PFUnDA, and PFDoDA exhibited significant positive linear associations with EPA/AA . Because only PFHpA and PFOA were associated with smoking, their concentrations were examined again with smoking variable included and neither showed an association with smoking habit. PFOA showed a significant linear association with EPA/AA ratio (p = 0.0072), but PFHpA did not (p = 0.051).In multiple linear regression analyses with age and eGFR, PFOA showed a significant positive linear association with age (The plasma concentrations of PFOA, PFNA, PFUnDA and PFDoDA significantly associated with the EPA/AA ratio in residents of Kyoto.  Per- and polyfluoroalkyl substances (PFASs) are a group of persistent organic chemicals that contain a carbon chain in which hydrogen atoms are replaced by fluorine atoms . The carPFASs are ubiquitously detected in the air, water, and soil ; therefoTo evaluate the contribution of seafood consumption to PFAS exposure, conventional biomarkers have previously been measured. Eicosapentaenoic acid (EPA) is a long-chain polyunsaturated omega-3 fatty acid that is most commonly found in fish, and arachidonic acid is an omega-6 fatty acid , 13. TheUji city is located in the southern area of Kyoto Prefecture, about 15 km south of Kyoto City, Japan. A 1-day event was held as part of health promotion program at a community center in November 2013. Flyers were distributed to each household in the city , that described the timing of the event and the measurements that would be made. Five hundred citizens visited this program, and they were informed on this study in the main session that all the visitors attended. Inclusion criteria was adult without blood coagulation disorder, living in Kyoto prefecture. Persons with end-stage renal disease were excluded due to possible difference in toxicokinetics of PFASs. Finally, one hundred thirty-one people were recruited to this study. They provided their written informed consent prior to participation. Demographic data and clinical history were obtained through face-to-face interviews using a structured questionnaire. This study was approved by the Ethics Committee of the Kyoto University Graduate School of Medicine .g for 15 min and stored at −30 °C at the Kyoto Human Specimen Bank until analyzed −. The reagent gas was methane  and supplied at 2 mL per min. The ion source temperature was maintained at 150 °C.The PFCA and fatty acid concentrations were measured using chemical ionization-mass spectrometry , according to the m/z ratio of [M-C2) was calculated using the age, sex, and serum creatinine concentrations of the participants [Kidney function was evaluated to determine its effects on the plasma PFCA concentrations, because renal clearance is likely to be the primary elimination route for PFASs , 23. An icipants .p-values < 0.05 were considered to represent statistical significance. However, it should not be interpretated as threshold of scientific significance [Continuous variables were summarized with means, standard deviations and medians. To compare plasma PFCA concentrations, concentrations below the limits of detection (LODs) were set as LOD/ificance . Differe2, and 0.59, respectively.The characteristics of the participants and their concentrations of PFCAs are shown in Tables All the PFCAs, except PFHpA and PFDoDA, were detected in all of the participants. However, PFHpA was detected in 99.2% and PFDoDA was detected in 98.5% of the participants, implying that almost seven PFCAs were detected in all the participants. PFOA was present at the highest concentrations, followed by PFNA. Table Next, the relationships between the plasma PFCA concentrations and demographic factors were evaluated. Table To adjust for the potentially confounding effects of age and eGFR, multiple linear regression analysis was performed. This showed that the plasma PFOA concentration significantly correlated with age; that PFHpA significantly correlated with eGFR; and that PFHpA, PFOA, PFNA, PFUnDA, and PFDoDA significantly positively correlated with the EPA/AA ratio Table .Because only PFHpA and PFOA were associated with smoking Table , we furtIn the present study, we found that several factors were associated with plasma PFCA concentrations in Japanese people in Kyoto. Notably, the EPA/AA ratio showed significant correlations with five of the seven PFCAs assessed in multivariable regression analyses .The plasma concentrations of PFCAs, and particularly of PFOAs, were similar to those identified in a previous study conducted in Japan . Of the Age was found to be significantly positively correlated with the concentrations of PFCAs, except for that of PFTrDA Tables –5. This PFCAs, except PFDA and PFTrDA, were found to negatively correlate with eGFR. This may suggest that PFCA is excreted in the urine. However, further analysis showed that only the concentration of PFHpA negatively correlated with kidney function. Shorter-chain PFCAs are more likely to be eliminated through renal clearance , 29. IndPreviously, Yamaguchi et al. demonstrated associations of plasma PFOS and PFOA concentrations with the EPA/AA ratio and seafood intake in Japan . This stThere were several limitations to the present study. First, the participants all lived in Kyoto, and therefore the described relationships cannot necessarily be generalized to other regions. The recruitment was based on the health promotion program and there should be a selection bias in the participants. Second, we did not take other possible routes of exposure into account, such as drinking water , personaSeveral plasma PFCA concentrations, and specifically those of PFOA, were found to positively associate with the EPA/AA ratio. In addition, PFHpA was found to negatively associate with eGFR. Seafood intake may represent an exposure pathway for these PFASs in the study population. However, we were unable to assess all the potential covariates that might affect the identified relationships with PFAS concentrations, and the small sample size with cross-sectional study design require confirmation in future studies. It is noted that the benefits of fish intake should not be undermined by this study results.


On the other hand, in the control group, significant differences were found in word reading test speed (p = 0.01), non-word reading test speed (p = 0.04), reading text test speed (p = 0.02), writing word test correctness (p = 0.01), writing non-word test correctness (p = 0.01) and writing sentences with homophonic words (p = 0.01). However, in this group, we observed no significant difference in the esteem of children. Training associated with the donkeys determined improved scholastic performances as far as reading is concerned and a change in self-esteem. Therefore, we can state that AAIs for dyslexia could be a viable and effective option to enhance the rehabilitation process, increase self-esteem and improve cognitive functions and language skills recovery.Dyslexia is a learning disorder related to receptive language characterized by difficulties with decoding, fluent word recognition, automatic naming skills and/or reading comprehension skills. It usually leads to severe functional impairment and the permanent need for support and interventions. Since animal-assisted interventions (AAIs) have been found to improve physical, emotional, cognitive and/or social functioning in humans, the aim of this study is to demonstrate the effectiveness of onotherapy on children with SLD by improving self-esteem and school performance. Sixteen patients with a diagnosis of dyslexia were randomly assigned to two treatment groups: the first was a conventional neuropsychological group therapy without onotherapy, and the second was a neuropsychological group therapy incorporating AAIs with therapy donkeys. The neuropsychological assessment included the WISC-IV, DDE and the TMA test, which were administered before and after the treatment in both groups. The results of the experimental group show significant improvement in word reading test correctness ( Specific learning disorders affect 1–2.5% of the general population in the Western world, and they include a diverse group of ailments in which children with preserved intellectual capacities have problems with processing information or generating output. Learning difficulties often lead to alterations in neurocognitive processes that can manifest themselves as a deficient ability to read, speak, write, organize information, solve mathematical problems, spell, listen or concentrate [Approximately 80% of people affected by learning disabilities have dyslexia, which is the most frequent learning disability ,4,5,6,7.Learning Disorders (SLDs) occur in an almost constant association with other disorders (comorbidities); this determines the marked heterogeneity of the profiles and the expressiveness with which SLDs occur, and it has significant repercussions on diagnostic investigations.Reading disability, or dyslexia, is a learning disorder based on receptive language characterized by difficulties with decoding, fluent word recognition, automatic naming skills and/or reading comprehension skills ,9. It geRapid progress is being made in understanding the etiopathogenesis of many learning disorder syndromes ,13,14, bDyslexia is a disability that evolves over time with results that are not easily predictable. Each dyslexic child can present with a different evolution, which depends on the multiple concomitant factors that can improve or worsen the evolution.Recent studies have examined some factors that can improve or worsen reading performance. Among these factors, Jakovljevic et al. found that gender  and coloThe construct of well-being is very complex, and various factors intervene, such as physical and psychological health, the quality of family and friends relationships, the sense of self-efficacy and self-esteem and emotional experiences. It has been seen that among children and adolescents, a good level of self-esteem is an indication of a healthy lifestyle . Some daTherapies using animals to improve cognitive, emotional, physical and social functioning are called animal-assisted interventions (AAIs) . The rehDonkey-assisted therapy for patients with SLDs could represent a valid treatment strategy as part of a multimodal therapy for children with SLDs and not just a playful-recreational activity and could lead to improved self-esteem in children with SLDs. The donkey should act as a facilitator of communication between the caregiver and the patient. Children benefit greatly from contact with the animal because of its sensitivity and the natural empathy that is established between them .Moreover, during onotherapy sessions, children could improve self-regulation  and selfThis study was conducted according to the Declaration of Helsinki. Our Institutional Ethics Committee approved the study protocol on 24 February 2021. Parents provided informed consent in both verbal and written forms.Sixteen patients with a diagnosis of dyslexia  with a range of 3–6 years of education that had been admitted to the Scientific Research and Care Institute “IRCCS Centro Neurolesi Bonino Pulejo” of Messina, were enrolled in this study. All of the participants were assigned randomly to one of two treatment groups: (a) a conventional neuropsychological group therapy without onotherapy (Control Group: CG n = 8); (b) a neuropsychological group therapy incorporating an AAI with therapy donkeys . Randomization minimizes the selection effect, and the two comparison groups allow us to determine the possible effects of the treatment compared to the group without treatment (control), while the other variables were kept constant. The inclusion criteria for this study were as follows: (1) a diagnosis of dyslexia according to the Diagnostic Statistical Manual, Fifth Edition (DSM-5); (2) aged between 8 and 11 years; (3) Q.I. normal (WISC score less than 80); and (4) the presence of low self-esteem (TMA score less than 86). The exclusion criteria were as follows: (1) the presence of other neuropsychiatric pathologies; (2) the presence of comorbidities; and (3) the presence of family conflicts that can affect self-esteem.The neuropsychological assessment in this study included the Wechsler Intelligence Scale for Children-IV (WISC-IV) , the ItaThe WISC-IV is a standardized clinical tool used for the cognitive assessment of children and young people aged between 6 and 16 years. The four cognitive areas assessed by WISC IV correspond to specific indices, as follows: the Verbal Comprehension Index (VCI), the Visual–Perceptual Reasoning Index (PRI), the Working Memory Index (WML) and the Processing Speed Index (PSI). Moreover, WISC-IV allows, from the sum of these indices, the elaboration of three composite ones, as follows: one index for Global Intellectual Quotient (IQ), one index for General Ability (IAG) and at least one for Cognitive Competence (ICC). WISC-IV is mainly used to support diagnostic hypotheses in the assessment of children with specific learning disorders (SLDs). In Italy, in fact, to diagnose an SLD, the subject must have an IQ of at least 85 and a significant discrepancy between their scholastic performance and their IQ .The DDE is a battery used in the assessment of the level of competence acquired in writing and reading, and it is very useful for monitoring progress during and after treatment. The DDE is divided into 8 tests. Of these tests, 5 aim to assess and analyze the reading process, requiring the subject to name graphemes, read words and non-words, understand sentences with homophones and correct homophones. On the other hand, the remaining 3 tests of the battery aim to assess and analyze the reading process by asking the subject to write words and non-words under dictation and write sentences with homophonic words under dictation. This battery has been recognized by the Italian Dyslexia Association as part of the basic diagnostic protocol for the evaluation of disorders in terms of writing, reading and calculation. It also makes it possible to compare pre- and post-treatment performance and promote communication between rehabilitation centers and operators.The TMA  assessesOne group (EG) underwent bi-weekly individual neuropsychological training associated with donkey-assisted therapy training once a week, and a control group (CG) underwent traditional individual neuropsychological training. Children with SLDs were recruited and diagnosed at our Child Neuropsychiatry clinic with the following battery: detailed medical history, neuropsychiatric visit and WISC-IV for an intelligence assessment. School performance was assessed using the DDE battery for the assessment of reading, writing and arithmetic. The level of self-esteem was assessed through the Italian version of the Multidimensional Self-Esteem Test—TMA. The training lasted for 6 months, at the end of which the children were re-checked again with the administration of school tests and TMA.Each training session lasted 45 min and was divided into 5 phases of 10 min each, unlike the last one, which lasted 5 min. The first phase of donkey-assisted training consists of interaction with the donkey and an introduction to the environment in which they live. This was followed by a phase of grooming, cleaning and physical contact to teach the children basic safety rules, animal anatomy and etiology and animal management issues. The third phase involved the children conducting the donkey along the path used for exercise, and the fourth phase was dedicated to saddling, riding and leading the children on the donkey in the field while invited to perform specific exercises. From these two phases, the children could learn basic aspects of riding . This allows the children to increase motor abilities and coordination, self-esteem and sensor perception. During the last phase, the children were dismounted and encouraged to socialize and relate to the animal for greetings (saying “goodbye” and hugging the donkey).p < 0.05.With regard to statistical analysis, nonparametric analysis was performed because the results of the Shapiro normality test highlighted a non-normal distribution of most of the target variables. The numerical data are presented as the median and the first-third quartile as a non-normal distribution. The Wilcoxon signed-rank test and the Mann–Whitney U test were utilized for intra and inter-group analysis, respectively. An interaction effect analysis (improved time) was performed by submitting the T1–T0 differences in the variables scores to correlation and regression analyses. Spearman correlation was used to evaluate whether there was a relationship between the DDE battery and the TMA sub-test. The analyses were performed using an open source R3.0 software package. The confidence level was set to 95% with a 5% alpha error. Statistical significance was set at The Wilcoxon signed-rank test showed a significant difference in the experimental group between T0 and T1 .p = 0.03) and speed (p = 0.03), non-word reading test speed (p = 0.01), reading text test correctness (p = 0.05) and speed (p = 0.03), word writing test correctness (p = 0.01), non-word writing test correctness (p = 0.02), writing sentences with homophonic words correctness (p = 0.01), interpersonal TMA (p = 0.04) and total TMA (p = 0.04) were significant. Moreover, a trend was present between non-word reading test correctness (p = 0.07), emotional TMA (p = 0.08) and scholastic TMA (p = 0.08) between T0 and T1. In the control group, we found significant differences in word reading test speed (p = 0.01), non-word reading test speed (p = 0.04), reading text test speed (p = 0.02), writing word test correctness (p = 0.01), writing non-word test correctness (p = 0.01) and writing sentences with homophonic words (p = 0.01). In this group, we have no heightened significant difference between T0 and T1 in the TMA sub-test. In the inter-group, we found a significant difference in the word writing test (p = 0.02) at T1 (p = 0.07) in the experimental group  at T1 . Spearmaal group .People with specific learning disorders may have lower levels of self-esteem and present more difficulties in terms of emotional and behavioral fields than those without dyslexia. However, the nature of the relationship between self-esteem and psychopathology remains unknown . This stThere were significant improvements in both the control group and the experimental group. While in the control group, the improvements concern only word reading test speed, non-word reading test speed, reading passage speed test, writing word test correctness, writing non-word test correctness and writing homophone word test correctness, but there were no improvements in the esteem of the children, in the group who underwent onotherapy associated with traditional training, in addition to the improvements already recorded in the control group, there is also an improvement in the correctness of reading the passage but above all in both global and interpersonal self-esteem. It is evident that the positive change in dyslexia is the result of the traditional cognitive training of reinforcement of the deficient areas, but the training associated with the donkey determined improved scholastic performances as far as reading is concerned and a positive change in the self-esteem values, which were not present in the control group. There is a lack of high-quality evidence on which to base any decision about the use of animal-assisted therapy for dyslexic children. Previous studies have demonstrated that children with reading difficulties presented decreased emotional and executive function abilities . There iThe various intervention methods used to improve the literacy, cognitive function and reading ability of children with dyslexia include the use of colored backgrounds or layouts ,17, multThe outcomes of this study suggest that there is an important function in the child–donkey interaction that can affect positive changes in terms of self-esteem and learning.Our results generate hypotheses regarding the role of the child–donkey interaction requiring further investigation. One hypothesis is that working together with the donkey involves the stimulation of nonverbal joint attention, shared attention, executive attention and memory that serve as a platform for improving linguistic abilities. Additionally, motor training with the donkey also has positive effects on several cognitive domains, including attention, memory, processing speed and inhibition beyond mood and mobility. Another hypothesis is that the child’s experience with the equine  creates a calming context, which could have a calming effect on children with dyslexia and, consequently, improve their performance in school tests due to an increased ability to concentrate. In addition, motor training with the donkey, featured in our protocol, could bring about positive effects on several cognitive domains, including memory, attention, inhibition and processing speed, in addition to acting on mood and mobility. All of this would, in our opinion, promote the improvement of self-esteem in the experimental group, as evidenced by the results obtained, reporting an increase in the total score on the total TMA score and in the interpersonal TMA score. Self-esteem could be improved thanks to the human–donkey interaction defined as “total grooming”, as it is linked to the idea of parental care, where the patient is rocked and pampered by the parents . The relA diagnostic category that is often not referred to when discussing equine-assisted therapy is mental illness. A study conducted by Punzo et al. found that children and adolescents suffering from mental illness find relief from everyday anxieties and fears and improve their self-esteem thanks to the friendship established with the animal, strengthening their self-confidence . SimilarIn conclusion, this study demonstrates that an AAI using donkeys in a rehabilitation program could be a motivational and effective tool for enhancing language skills, favoring cognitive functions, promoting psychological well-being and improving self-esteem. Further larger sample studies with long-term follow-up periods are needed to confirm the effect of this interesting approach. The conclusions are preliminary, and the limitations of the study include the small number of subjects and a lack of a longer follow-up, and that it is not randomized. The value of the current small study only points in one direction, increasing self-esteem in children with dyslexia, and no firm conclusions can be drawn yet.


Linear and non-linear analysis clearly support the role of both personality traits and decision-making styles in risky driving behaviors. Aggressiveness, Sensitivity to Reward, Sensation Seeking played the main role from personality traits, and Spontaneous and Rational decision-making style also accounted for some variance regarding risky driving behaviors. This pattern was broadly replicated in both genders. The discussion section analyses congruencies with previous literature and makes recommendations on the grounds of observed results.The present study was planned to study the relationships between age, personality  and decision-making styles in relation to risky driving behaviors. The participants were habitual drivers, 538 (54.3%) men and 453 (45.7%) women, with a mean age around 45 years and mainly of middle socioeconomic status. The results indicate that the youngest men and women reported more Lapses, Ordinary violations, and Aggressive violations than the oldest men and women. Women reported more Lapses ( A global status report on road safety by Lapses, Errors, Ordinary violations, and Aggressive violations  a negative association between age and risky driving, (b) significant higher scores of women in driving lapses, while men would have higher scores in ordinary/aggressive violations, (c) Aggressiveness, Sensation Seeking and Reward to Sensitivity would be related to some aspects of risky driving, and (d) people with Rational decision-making styles are expected to have fewer Lapses, Errors, and Ordinary/aggressive violations, while avoiders and, especially, spontaneous people would have more Lapses, Errors, and Ordinary/aggressive violations. We also compare the predictive power of personality traits and decision-making styles regarding risky driving.2.2.1.SD = 16.07) and 44.04 (SD = 15.25), respectively. The age range was 18–90 years with a normal distribution (kurtosis = −0.64 and skewness = −0.14). The sample was obtained from the general population with the help of students, who administered the questionnaire protocol anonymously and voluntarily to healthy members of the community. Each student was required to recruit men and women from the following age ranges: 18–35, 36–45, 46–60, and more than 60 years. The Hollingshead Social Position Index  were men and 453 (45.7) were women. The mean ages for men and women were 45.67 (on Index  was obta2.2.2.2.1.strongly disagree) to 4 (strongly agree). The questionnaire has five personality domains: Aggressiveness (AG), Activity (AC), Extraversion (EX), Neuroticism (NE), and Sensation Seeking (SS) and 20 facets  to 5 (strongly agree). The confirmatory factor analysis supported the five-factor structure of GDMS as well as measurement invariance across gender. Alpha internal consistency values ranged from 0.72 to 0.91.The GDMS  is a selThe GDMS has five different scales, each representing a decision-making style: Rational (RA), Intuitive (IN), Dependent (DE), Avoidant (AV), and Spontaneous (SPO).2.2.4.The DBQ  has been2.3.Descriptive analysis, and comparisons between genders for age, social position and psychometric variables was performed. Cronbach’s alpha internal consistency value of the scales was also calculated. Graphical comparisons of the DBQ by age and gender ranges were also presented using ANOVA and Scheffe post-test. Additionally, an ANOVA 2×5 (gender x age ranges) was computed for the four scales of the DBQ. Zero-order correlations, independently for men and women, were also considered for all variables. In addition, empirical network analysis was used to analyze the unique relationships between age, ZKA-PQ, SPSRQ-20, GDMS and DBQ scales  of Nonparametric local LOESS graphical analysis  was also3.3.1.p < 0.001; d = 0.33), Aggressive violations , Sensation Seeking  and Sensitivity to Reward . In contrast, women obtained higher means in Lapses , Intuitive  and Dependent  decision-making style, and personality traits such as Neuroticism  and Sensitivity to Punishment . Alpha coefficients showed adequate values in all scales.3.2.The differences between age in both genders in the four DBQ scales are presented in p < 0.001) and age (p < 0.001), but not for the interaction. For the error scale, it was only significant for age (p < 0.003). Regarding ordinary violations, there was a significant effect of gender (p < 0.001), age (p < 0.001) and the interaction (p < 0.04). This interaction effect is due to the higher mean score of the youngest men. Similarly, differences on Aggressive violations were associated with gender (p < 0.001), and age (p < 0.001). The interaction was also significant (p < 0.003). Again, this interaction effect is mainly due to the higher mean score of youngest men. However, it should be mentioned that the interaction effect, when significant, presented an eta squared (η2) of about 0.01 indicating a rather small effect on the DBQ scales. Age presented η2 higher than gender in all but the Lapses variable. The largest η2 obtained were for the age factor on Ordinary (0.10) and Aggressive violations (0.07). Both values suggest a medium effect size.Complementary to this analysis, an ANOVA 2×5 (Gender x Age range) was performed to test the possible interaction effects between the gender and age variables. This analysis also allows for testing the effect size of the gender, as well as age variables and the interaction. For the Lapses scale, F was significant for gender (3.3.As can be seen in 3.4.p < 0.001). The variance accounted for by the three factors was 50.03%. The first factor grouped the four scales of DBQ and, with a lower loading, the Rational decision-making scale in negative. As the four DBQ scales present high and positive correlations and load on the same factor, it sounds psychometrically appropriate to compute a single score. This result allows us to compute a regression analysis on the DBQ single score what is more informative about the personality correlates of the risky driving behavior than using each DBQ separately. The second factor grouped the Neuroticism scales, including Sensitivity to Punishment, Extraversion (−), the decision-making scales related to Neuroticism (Avoidant and Dependent) and Aggressiveness. The third was a factor of Sensation Seeking, Sensitivity to Reward  and Activity. The most disinhibited decision-making styles -Spontaneous and Intuitive- and Activity trait were also included. It is important to remark that Aggressiveness loaded on the three factors, and that the loading on its own factor is quite similar to the loading on the risky driving factor (the first).Another way to study the relationships among risky driving scales, personality, and decision-making variables is to perform a Principal Components Analysis (PCA) with Varimax rotation . Three fA multiple linear regression analysis was also carried out separately for men and women with the aim of identifying the best predictors of total DBQ score using age, personality traits and decision-making styles as independent variables . Age (−)3.5.4.This study analyzes altogether the role of age, gender, personality traits (Zuckerman’s and Gray’s models) and decision-making styles on risky driving in a large sample of middle social position and gender parity, and with an age distribution similar to that of the general population. Our purpose was to contribute to this field of research by deepening our knowledge about the role of individual difference variables such as personality traits and decision-making styles on motor vehicle driving behavior. First, this study replicates the gender differences on risky behavior scales. Women scored higher on lapses, and men on ordinary violations in all age ranges . Men alsWith regard to the role of independent variables, most studies indicate that age, and to a lesser extent gender, are strong predictors for risky driving behavior . The resMore centrally to the aims of the study, personality traits proved to be associated with risky driving in both men and women. The personality trait most associated with risky driving was Aggressiveness in both genders. These results for Aggressiveness and driving are consistent with the findings of A contribution of this study is the fact that decision-making styles add predictive power to risky driving beyond personality traits. Congruent with the literature, rational style is the decision-making style most related with risky driving behavior. Note that the relationship is negative, so this decision-making style seems to act as a protector in risky driving, in agreement with other studies . This reOur results corroborate the findings of previous research that has studied the relationships between personality and decision-making scales and risky driving separately. In our study, we have tried to investigate their relationships in a more integrated way. Furthermore, to the best of our knowledge, this is the second study to use the ZKA-PQ in driving behavior research. Note that most studies have used the FFM. In addition, the inclusion of a personality measure according to Gray’s model makes it possible to analyze the role of impulsivity (defined as Sensitivity to Reward) from a complementary perspective, more inspired by the biological tradition of personality research.Considering the linear results observed in the present paper, drivers with high scores on risky driving could be defined as young, more aggressive, high in Neuroticism (and Sensitivity to Punishment), Sensation seekers, and low in rational, and high in avoidant and spontaneous decision-making styles. It prompts the following considerations: (1) It provides some insight into the phenomenon that the overall crash rate steadily decreases as driver age increases. There is ample evidence that age is strongly negatively associated with disinhibited personality traits such as Sensation Seeking, Aggressiveness, and Sensitivity to Reward . In addiAs a secondary aim of the present study, we replicated the observed relationships among variables analyzed in the present study. As has been commented above, the negative relationship among age and some personality traits was replicated. Gender differences in personality traits match those expected according to the literature. Women score higher on Neuroticism and Sensitivity to Punishment, and men on Sensation seeking and Sensitivity to Reward . There wThis study has strengths and limitations. Among the strengths is the large sample of anonymous drivers with gender parity and a wide age range, the use of questionnaires validated in the same sociocultural context, and the good internal consistency of the different scales. The basic limitation is the fact that the study was carried out with data obtained through self-reported questionnaires. Cross-sectional surveys have an inherent method bias. Independent and dependent variables are measured at the same time, which makes it difficult to distinguish between cause and effect. In this sense, it would be desirable to use longitudinal designs using, for instance, a panel design. Thus, both individual and situational factors for risky driving could be better detected. It would also be advisable to use objective data on risky driving such as loss of points, number of sanctions or accidents, experience as a driver, and so forth, to complement self-report measures. For instance, not considering the exposure of the driver to risk, the frequency of driving or the usual mileage of the participant as covariates is a limitation of the present study . These vSumming up, the psychological description of risky drivers obtained in our large and representative sample of drivers is mainly characterized by young subjects, high scores in Aggressiveness, Neuroticism, Sensation Seeking, Sensitivity to Reward and Punishment, and decision-making styles characterized by low rationality, and high spontaneity. The present study demonstrates that personality traits and decision-making styles play a complementary role in the prediction of risky behavior. Finally, the present study closely replicates in the Spanish population the association of age with risky driving, as well as the different pattern of risky behaviors observed in men and women in other countries.The datasets presented in this article are not readily available because they are subject to ongoing research. Requests to access the datasets should be directed to the corresponding author.The studies involving human participants were reviewed and approved by the Ethical Commission of the University of Lleida. The patients/participants provided their written informed consent to participate in this study.AA and FB designed this study and conducted the statistical analyses. All authors collected the data, contributed to the writing and editing of the manuscript, and approved the final version.This research was funded by a grant from the Spanish Ministry of Economy, Industry and Competitiveness (PID2019-103981RB-I00). All the authors took part in this project as researchers.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


OBJECTIVE: This study aims to establish the effect of electromagnetic diathermy therapies  on pain, function, and quality of life in treating musculoskeletal disorders. METHODS: We conducted a systematic review according to the PRISMA statement and Cochrane Handbook 6.3. The protocol has been registered in PROSPERO: CRD42021239466. The search was conducted in PubMed, PEDro, CENTRAL, EMBASE, and CINAHL. RESULTS: We retrieved 13,323 records; 68 studies were included. Many pathologies were treated with diathermy against placebo, as a standalone intervention or alongside other therapies. Most of the pooled studies did not show significant improvements in the primary outcomes. While the analysis of single studies shows several significant results in favour of diathermy, all comparisons considered had a GRADE quality of evidence between low and very low. CONCLUSIONS: The included studies show controversial results. Most of the pooled studies present very low quality of evidence and no significant results, while single studies have significant results with a slightly higher quality of evidence (low), highlighting a critical lack of evidence in the field. The results did not support the adoption of diathermy in a clinical context, preferring therapies supported by evidence. Musculoskeletal disorders (MSDs) affect 1.71 billion people globally, with impressive financial costs for healthcare systems . AccordiRehabilitation of MSDs is delivered by multi-professional teams. Interventions vary according to disorders and impairments; evidence-based treatments are not always common and shared, even within the same countries, where therapists perform different treatments to manage the same condition. However, non-specific rehabilitation interventions are common and performed in different countries. Among them, diathermy is used in different modalities by physicians in low- and middle-income countries as well as in high- and very-high-income countries for the treatment of MSDs ,5,6.Diathermy is identified by the U.S. Food & Drug Administration as a therapeutic modality that produces deep heating under the skin, muscles, and joints for therapeutic purposes. FDA classifies it into three forms: shortwave diathermy (SWD) , microwaThe field of use of these therapies is wide, but mainly centred on MSDs ,17,18. HThis systematic review aims to assess the effect of electromagnetic diathermy, primarily on pain and function, and secondarily on quality of life (QoL), patient-rated overall improvement, and adverse events in adults with MSDs. This systematic review of literature was conducted following the Cochrane Handbook for Systematic Reviews of Interventions (Version 6.3) and the PRISMA Checklist 2020 . The proWe included published randomized controlled trials (RCTs) in English, Italian, Spanish, and Dutch. Adults suffering from MSDs, with no age limitation, were included. MSDs were identified according to the definitions proposed in the MESH term definition, in the Emtree description, and according to the WHO definition of musculoskeletal conditions. SWD, MWD, and CRET were considered, compared with any other intervention, sham and placebo included, or with no treatment.SWD produces deep heat of subcutaneous tissues by the oscillation of high frequency  electromagnetic fields, with the interposition of two condenser probes  independently screened the records for title, abstract, and full text using the software Rayyan . DisagreTwo reviewers [RB and JP] extracted the data in a predefined excel sheet. Data were extracted regarding the study, methods, participants, interventions, outcomes, and notes.‘Risk of bias tool 1.0′ was used to assess RCTs using the criteria recommended by Cochrane . Two revStandardized mean differences (SMD) with 95% confidence intervals (95% CI) were calculated for continuous data. Mean difference (MD) was calculated for pooled studies with the same outcome measure and non-pooled studies. ‘GRADE handbook for grading quality of evidence and strength of recommendations’  and GRADhttps://automeris.io/WebPlotDigitizer/ (accessed on 28 February 2023)” to extract the values. In the case of data presented as median and interquartile range or minimum and maximal value, the mean and standard deviation was calculated according to the method proposed by Wan et al. [Where data were not extractable or not fully reported, corresponding authors were contacted. To retrieve data, when they were presented graphically, or with missing means, we used the methods proposed by Cochrane Handbook ,26. In tn et al. .Data were summarized by MSDs. For each disorder, data were presented for the outcomes considered in this systematic review . Where possible, the results of the studies were pooled according to the type of diathermy utilized in the intervention , considering similar comparisons to reduce a source of heterogeneity.The database search identified 13,323 records, and 79 extra records were identified through other methods. After the screening process, 69 reports of 68 studies were included. The full process has been synthesized in We found 17 treated MSDs. The pathology most considered was OA, with 27 studies included in the review (40%), followed by LBP, with 12 studies (18%). The risk of bias graphs  show forTwenty-seven studies ,86,87,88p = 0.11) and a heterogeneity, I2, of 64% (GRADE: low certainty), p = 0.98), with 0% of heterogeneity (GRADE: very low certainty), p = 0.43), and a heterogeneity of 79% (GRADE: very low certainty), p = 0.43), and 94% of heterogeneity (GRADE: very low certainty), p = 0.14) and a 58% heterogeneity for the post-treatment assessment (GRADE: very low), p = 0.88), and a heterogeneity of 24% (GRADE: low certainty), p = 0.54) and 0% of heterogeneity (GRADE: very low), All 27 studies considered pain relief as an outcome. Eleven studies compared diathermy and a placebo or sham diathermy treatment . SWD was compared with sham treatment in 7 studies ,34,35,36p = 0.54), and I2 of 30% for the PT assessment (GRADE: low), p = 0.40), and 0% of heterogeneity for (GRADE: very low), p = 0.33), and I2 = 81% (GRADE: very low), p = 0.70) and I2 = 93% (GRADE: very low), p = 0.35), and I2 = 92% post-treatment (GRADE: very low), p = 0.81) and I2 = 6% (GRADE: Low), p = 0.15), and heterogeneity of I2 = 38% (GRADE: very low), p-value for the differences between SWD and sham SWD and for the comparison between SWD and ice application, so it was not possible to evaluate the effectiveness of the intervention. All the non-pooled comparison values of MD are presented in Twenty-six studies ,86,87,88p = 0.002) in favour of SWD therapy, and no heterogeneity (I2 = 0%). All the non-pooled comparison values of MD are presented in Six studies ,45,49,50p = 0.86), and no heterogeneity (I2 = 0%). Cantarini 2006 [Three studies ,44,45 asThe GRADE assessment for the certainty of evidence for the main outcomes considered in the studies in patients with OA ranges from low to very low.Twelve studies ,89,90,91p = 0.05) and I2 of 95% (GRADE: very low), p = 0.006), and I2 of 95% (GRADE: very low), p < 0.01) for VAS daytime and nocturnal pain score, both after treatment and at IT. A comparison between groups was not presented. Farrell 1982 [Two studies ,55 compaell 1982  comparedp < 0.05), while no other significative improvement in lumbar motion was reported. Wachi 2022 [Eight studies ,74,89,90chi 2022  comparedOnly the non-pooled data of the Durmus 2014 study compared the effects of diathermy + active exercises vs. only active exercises on the QoL, and did not find significant changes in favour of any of the two groups .The GRADE assessment for the certainty of evidence for the main outcomes considered in the studies in patients with LBP ranges from low to very low.Six studies ,77,78,92All 6 studies assessed improvements in function. Non-pooled data for improvement in function in Yilmaz Kaysin’s 2018 study revealed significant changes in favour of SWD compared with sham SWD at the short-term follow-up  and at the intermediate follow-up . Similarly, non-pooled data for improvement in function in Giombini’s 2006 study found significant changes in favour to MWD comparing it with active exercises at post-treatment  and at intermediate-term follow-up . In the same study, a comparison between MWD vs. ultrasound therapy showed significant changes in improvement in function in favour of MWD post-treatment  and at intermediate-term follow-up . In contrast, non-pooled data for improvement in function in Akyol’s 2012 study  reportedAkyol 2012 and Avendaño-Coy 2022 assessed QoL improvement, but did not underline any significant changes in favour of any considered groups at any time point .The GRADE assessment for the certainty of evidence for the main outcomes considered in the studies in patients with STN ranges from low to very low.Three studies ,61,85 evThe GRADE assessment for the certainty of evidence for the main outcomes considered in the studies in patients with FS is very low.p = 0.03) in favour of SWD, with I2 = 0. (GRADE: low), p = 0.46), and I2 = 88%. (GRADE: very low), Three studies ,63,79 prThe GRADE assessment for the certainty of evidence for the main outcomes considered in the studies in patients with CTS ranges from low to very low.Two studies ,81 treatThe GRADE assessment for the certainty of evidence for the main outcomes considered in the studies in patients with LLT is very low.Two studies ,82 evaluThe GRADE assessment for the certainty of evidence for the main outcomes considered in the studies in patients with NP ranges from low to very low.Two studies ,93 verifVerma 2012 reported significant relief in both groups (SWD + active exercises vs. taping + active exercises) but did not compare the results of the two interventions. Moreover, this study showed a significant improvement in function in both groups without comparing the two interventions. Non-pooled data of the Albornoz-Cabello 2020 study highlighted significant changes post-treatment in favour of monopolar dielectric radiofrequency + active exercise in pain relief , and improvement in function  compared with only active exercise .The GRADE assessment for the certainty of evidence for the main outcomes considered in the studies in patients with PFP is very low.Two studies ,67 treatThe GRADE assessment for the certainty of evidence for the main outcomes considered in the studies in patients with TMJ is very low.p = 0.638) among the CRET, Sham CRET, and Massage groups. Nakamura 2022 showed no significant changes comparing CRET vs. no intervention in improvement in function (Two studies ,95 utilifunction .The GRADE assessment for the certainty of evidence for the main outcomes considered in the studies in patients with DOMS is low.The study of Livesley 1992  comparedBadur 2020  comparedThe GRADE assessment for the certainty of evidence for the main outcomes considered in this study in patients with UNE is low.Babaei-Ghazani 2019  comparedThe GRADE assessment for the certainty of evidence for the main outcomes considered in this study in patients with LE is low.The study of Pasila 1978  comparedGiombini 2001  comparedThe GRADE assessment for the certainty of evidence for the main outcomes considered in this study in patients with LAMI is very low.Georgoudis 2017  investigGarcía-Marín 2021  studied The GRADE assessment for the certainty of evidence for the main outcomes considered in this study in patients with TKR is low.This systematic review aimed to evaluate the effectiveness of electromagnetic diathermy for treating MSDs to reduce pain and improve function. The role of diathermy within treatment protocols was found to be very varied. It was proposed as a stand-alone therapy, especially when compared with sham intervention, as a component of multimodal treatment, or even considered within the usual care intervention. Consequently, diathermy was proposed within the experimental and control groups. Diathermy was used as a treatment in 17 different MSDs. Both acute and chronic conditions were treated, based on the positive effect that thermotherapy can add to the treatment of these conditions ,98. HoweIn those MSDs where only few studies could be pooled, high levels of heterogeneity were retrieved, even if the manageable sources of heterogeneity were considered. This can represent a sign of deficiency in the study conduction of some of the primary studies.2 from 64% to 0%, but would not have changed the pooled result. In addition, Wang et al. combined the placebo and no-treatment groups, as in Fukuda 2011, whereas we did not consider them two different interventions. Other authors have performed systemic reviews on diathermy in MSD treatment. Contrary to our results, Wang et al.  reportedOther reviews ,99 reporThis study is the first systematic review that has assessed the effect of different types of electromagnetic diathermies on MSDs. Even if the pathologies, outcome, and the different types of diathermies considered create a huge number of results, the adopted methodology, and the methods of conducting were used to provide a confident response. It is well known that therapies based on heat, including electromagnetic diathermies, are widely adopted all around the world ,5,6, butDifferent studies included in this review provide clear, reliable, and encouraging results supporting diathermy treatments. However, the results of these studies should be confirmed by other trials, with large sample sizes and appropriate study designs.This review has some limitations; it did not provide a sensitivity analysis of the results. This is because the wide number of studies and pathologies included did not allow for such analysis. Further studies should investigate the specific pathologies and perform this analysis. Another limit of this review is that it did not show a strong clinical implication, even if in the treatment of knee OA meta-analysis results showed clearly that SWD is not effective. In some of the MSDs where more studies were retrieved, the unclear use of diathermy treatments with disparate treatment did not allow an extensive pooling of study results. Moreover, in other MSDs this review highlights the lack of evidence, with only single studies that provide limited results. In conclusion, the findings of our review are influenced by the scarce quality of evidence. Further studies should perform trials with a larger sample size, experimental interventions based on diathermy as a stand-alone therapy to reduce the complexity of multi-approach protocols, control interventions defined according to MSDs guidelines, and a reduction of sequence generation and allocation bias. The studies published up to now, even if providing a low quality of evidence, do not allow us to suggest the use of diathermy in clinical settings or its wide implementation within rehabilitative protocols. Indeed, there is no strong evidence that diathermy is preferable to placebo/sham intervention or other interventions for treating MSDs, even if in some specific cases diathermy showed significant results.


Insulin resistance (IR) is a prominent feature of polycystic ovary syndrome (PCOS). The importance of lifestyle interventions in the management of PCOS is strongly highlighted and it is suggested that diet and physical activity may significantly influence insulin sensitivity. Therefore, we evaluated the link between diet and physical activity and various indices of insulin resistance, including adipokines secreted by the adipose tissue in 56 PCOS and 33 healthy control women. The original food frequency questionnaire and Actigraph GT3X-BT were used to assess the adherence to the diet recommended in IR and the level of physical activity, respectively. We observed that higher levels of physical activity were associated with lower HOMA-IR and a greater chance of its normal value in PCOS group. No such relationship was observed for other IR indices and adipokines or for the diet. However, we noted a strong correlation between HOMA-IR (Homeostatic Model Assessment of Insulin Resistance) and HOMA-AD (Homeostatic Model Assessment-Adiponectin) in PCOS women. Additionally, when we used HOMA-AD we observed a higher prevalence of IR among PCOS women. Our study supports the beneficial role of physical activity in the management of insulin resistance in PCOS women. Moreover, our findings indicate that HOMA-AD may be a promising surrogate marker for insulin resistance assessment in women with PCOS. Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders affecting women of reproductive age. It is a complex condition commonly associated with anovulation, hyperandrogenemia  and/or polycystic ovary morphology . The preUntil recently, PCOS had only been considered as a cause of reproductive failure; however, it is now well-acknowledged that PCOS women are particularly susceptible to the development of many cardiometabolic disorders. Additionally, PCOS is strongly associated with obesity, which has an impact on the metabolic and reproductive complications in the course of this disease. As a result of hyperandrogenism, PCOS women are more likely to have abdominal obesity with increased content of visceral or subcutaneous fat compared to healthy women. Interestingly, the excessive accumulation of the visceral adipose tissue is also reported in PCOS women with normal body weight; thus, this parameter is not only related to BMI (body mass index). In addition, such fat distribution is strongly linked to hyperglycemia, compensatory hyperinsulinemia and insulin resistance ,4. MoreoInsulin resistance (IR) is defined as reduced insulin sensitivity and refers to an increased amount of insulin needed to perform its metabolic actions . It is aIt is suggested that diet and physical activity significantly influence insulin sensitivity. Importantly, the role of dietary patterns in relation to IR is remarkable and quite well proven ,13,14,15Bearing in mind the fact that IR that accompanies PCOS does not only aggravate the hormonal imbalance and ovulation disorders but it also increases the risk of cardiometabolic complications, it is important to establish the role of a balanced diet and physical activity in the management of IR in this disease. Therefore, in this study we aimed to evaluate the link between diet and physical activity and various indices of insulin resistance, including adipokines secreted by the adipose tissue. This case-control study included 56 women with polycystic ovary syndrome and 33 healthy control women, who were enrolled in the Department of Gynecological Endocrinology of the Medical University of Warsaw in 2021–2022. The inclusion criteria for the study group were as follows: age between 18 and 40 and polycystic ovary syndrome diagnosed according to the Rotterdam diagnostic criteria. They included the presence of at least two of the following three criteria: oligo-/amenorrhea, clinical and/or biochemical hyperandrogenism and polycystic ovaries detected via ultrasound exam . Exclusi2). The interpretation of the ratio was based on the classification specified by the World Health Organization (WHO): <18.5 kg/m2—underweight; 18.5–24.9 kg/m2—normal weight; 25.0–29.9 kg/m2—overweight; and ≥30.0 kg/m2—obese /405); HOMA-AD  × fasting glucose (mmol/L)/adiponectin (μg/mL)] and L/A /adiponectin μg/mL). The defined cutoff points for different insulin resistance indices used were HOMA-IR ≥ 2.5 , HOMA-AD, respectively. Total adiponectin was determined using a kit manufactured by TECOmedical AG  with a lower detection limit below 0.27 ng/mL, intra-assay CV of 3.14–3.67% and inter-assay CV of 6.93–8.16%. Resistin was measured using a kit manufactured by Mediagnost ; the analytical sensitivity of the assay was 0.012 ng/mL, while the intra- and inter-assay CV were 4.49–4.97% and 3.37–6.67%, respectively.The concentrations of serum adipokines were determined via commercial enzyme-linked immunosorbent assay (ELISA) according to the manufacturer`s instructions. Leptin was assessed using a kit from DRG Instruments GmbH . The analytical sensitivity of the assay was 0.7 ng/mL, while intra- and inter-assay coefficients of variation (CV) were 4.2–7.3% and 3.7–9.1%The assessment of the women’s nutrition was based on the original food frequency questionnaire (FFQ), which was conducted during a face-to-face interview with a qualified nutritionist. The FFQ consisted of 15 items which have a negative or positive relationship with the sensitivity of tissues to insulin. The main food products included wholegrain cereal products, refined cereal products, natural yoghurt, fruits, vegetables, vegetable oils (including avocado and soft margarines), animal fats , nuts, legumes, red meat, processed red meat, fatty sea fish, sweet drinks, sweets (including sugar) and fast food. The participants were asked to report their average frequency  and portion sizes for consumption of each food item. The sizes of declared food portions were verified using the “Album of Photographs of Food Products and Dishes” from the National Food and Nutrition Institute .Based on the awarded points , the score of the adherence to the diet recommended in insulin resistance was calculated. A greater number of points received by a subject translated into greater compliance with the diet, lowering insulin resistance. The maximum number of points that could be obtained was 15.Physical activity was measured using an Actigraph GT3X-BT activity monitor  worn for 7 consecutive days at an elastic belt around the waist and positioned on the right hip. Raw accelerometer data were downloaded using ActiLife software . The intensity of physical activity was measured using cut points for adults established by Freedson et al. . To estiAll calculations were performed with STATISTICA TM 13.3 software . Variable distributions were evaluated with the D’Agostino’s K-squared test and descriptive statistics  were calculated. Due to the fact that the Study and Control Groups were not of equal sizes, the Mann–Whitney–Wilcoxon test was used to compare differences between them. The contingency tables with the Fisher’s exact test or chi-square test were used to assess the relationship between the frequency of insulin resistance in various measures. p-values of <0.05 were considered statistically significant. Linear regression analysis was used to assess the relationship between the examined parameters and physical activity or diet scores. The least square estimation was used to estimate parameters for linear regression. A standardized regression coefficient (β) with a 95% confidence interval (95% CI) was estimated for each independent variable included in the model. Logistic regression analysis was performed in order to examine the chances of normal values of the examined parameters depending on the scores for diet or physical activity. The maximum likelihood method of estimation was used to estimate parameters for logistic regression. For each independent variable included in the model, an odds ratio (OR) with a 95% confidence interval (95% CI) was estimated. Correlations between variables were examined using Pearson’s correlation coefficient. p = 0.008), BMI (p = 0.004), waist circumference (p = 0.003), total fat mass (p = 0.008), visceral fat (p = 0.018) and subcutaneous fat (p = 0.003) compared to healthy control women. Interestingly, the VAT/SAT ratio was also higher in this group, though the difference was not statistically significant.The characteristics of PCOS and control women, i.e., the age and height, were comparable and were not significantly different. As expected, the anthropometric and body composition data showed several differences between the groups. Women with PCOS had significantly higher body weight (p < 0.001). However, we did not observe any significant differences in leptin and resistin levels. Women with PCOS had significantly higher L/A ratios compared to healthy women (p < 0.001). Interestingly, women from the Study Group had lower HOMA-IR values compared to the Control Group, though the difference was not statistically significant. This result was in contrast to another measure of insulin resistance, i.e., HOMA-AD, where the results clearly differed between the groups. PCOS women were characterized by significantly higher HOMA-AD compared to control women . Biochemical blood parameters also showed differences between groups. PCOS women had a significantly lower concentration of adiponectin compared to control women . Similarly, moderate and vigorous physical activity levels were also significantly lower . We did not observe significant differences between the diet scores between the Study and Control Groups (p = 0.280). The detailed comparisons of anthropometric data, body composition measures, biochemical parameters and the diet score are shown in PCOS Group was characterized by significantly lower MVPA compared to the Control Group . Moreover, the correlation was much stronger in the group of women with PCOS. The Pearson’s correlation coefficient revealed a strong positive correlation between HOMA-IR and HOMA-AD in the Study and Control Groups (p = 0.0029). Finally, the L/A ratio used to assess insulin resistance showed that 25 women with PCOS and only two women from the Control Group had abnormal results. According to the HOMA-IR index, 11 women with PCOS and 10 women from the Control Group were characterized by abnormal tissue sensitivity to insulin. Regarding the HOMA-AD index, as many as 22 women with PCOS had insulin resistance, while only 3 women had a score ≥ 6.26 in the Control Group. In addition, we noted that the probability of an abnormal HOMA-AD result was significantly increased in PCOS Group  and Control Groups . As regards women with PCOS, 11 had insulin resistance according to both indices, with only two such patients being found in the Control Group.In addition, we observed a relationship between the normal result obtained in HOMA-IR and HOMA-AD in both PCOS . However, there was no statistically significant relationship between those parameters in the Control Group. Moreover, there was no relationship between HOMA-IR and diet score both in PCOS and Control Groups. Additionally, no such relationship was observed between physical activity or the diet score and adipokines, HOMA-AD and the L/A ratio in both groups of women. Adjustment for BMI and MVPA did not affect the results. Linear regression analysis showed a differential effect of physical activity on the HOMA-IR value depending on the group. We observed that higher levels of physical activity (expressed as MVPA) were associated with lower HOMA-IR in PCOS Group (p = 0.010). However, no such relationship was observed in the Control Group. In addition, the diet score did not have an effect on normal HOMA-IR value in PCOS and control women. Similarly, no such link was observed between physical activity or the diet score and adipokines, HOMA-AD and the L/A ratio in both groups of women. Similarly to the previous analysis, adjustment for BMI and MVPA did not change the outcomes.In addition, logistic regression showed that there was a differential effect of physical activity on the normal level of HOMA-IR depending on the group. In the PCOS Group, higher levels of physical activity (expressed as MVPA) translated into a greater chance of a normal HOMA-IR level , BMI , waist circumference , fat mass , VAT , SAT  and VAT/SAT ratio . In this group, serum leptin and resistin were also significantly related to all the anthropometric and body composition measurements (moderate-to-strong positive correlations). As regards non-PCOS women, we noted that only leptin was significantly associated with anthropometric and body composition measurements and the correlations were mostly stronger than in PCOS Group.The analysis of the group of PCOS women revealed negative-to-moderate correlations between serum adiponectin and weight . As for the Control Group, only the correlation between fasting insulin and SAT was statistically significant . In case of fasting glucose, none of the relationships were significant.Fasting insulin and fasting glucose of PCOS women correlated positively with all measurements, except for fat free mass where the correlation was inverse . Interestingly, HOMA-IR was only correlated with SAT  in the Control Group. In PCOS Group, we noted the strongest positive correlation between HOMA-AD and weight , BMI  and VAT . Other HOMA-AD correlations were of moderate strength. In the Control Group, the correlations of HOMA-AD with anthropometric and body composition parameters were generally much weaker. Additionally, in PCOS women HOMA-AD was correlated with VAT/SAT ratio , whereas no such link was observed in non-PCOS women. We noted a similar relationship in case of the A/L ratio. Correlations between adipokines, insulin resistance markers and anthropometric measurements and body composition in PCOS and non-PCOS women are presented in detail in All IR indices were correlated with anthropometric and body composition measurements in PCOS women. HOMA-IR and the A/L ratio were the most strongly correlated with VAT  [In the present study, apart from HOMA-IR we used HOMA-AD to evaluate IR. To our knowledge, our study is the first one that uses HOMA-AD in a group of women with PCOS. HOMA-AD is a very promising marker for IR assessment because it also includes adiponectin, which is involved in the regulation of insulin sensitivity. This surrogate IR marker was first validated in Japanese adults and presented a stronger correlation with the euglycemic–hyper-insulinemic clamp technique than HOMA-IR (ctively) . A studyIn our research, we also proposed the L/A ratio to assess IR in PCOS women. It was previously suggested by Larsen et al.  that, inThe importance of physical activity in the prevention and treatment of many chronic diseases is well documented . StudiesNo relationship was observed between the amount of physical activity and the concentrations of all tested adipokines . The results obtained by Stener-Victorin et al. , CovingtThe importance of diet, in addition to physical activity, was clearly emphasized in the recommendations regarding the treatment of PCOS ,18. DespThe use of an accelerometer for the precise measurement of physical activity was a strength of our study. However, this study had several limitations. Firstly, the size of the Study and Control Groups was small. Secondly, the use of the original food frequency questionnaire based on declared frequency and portion sizes by the participants might lead to the under- or over-estimation of dietary intake. Finally, our population was mainly Caucasian, with the participants holding a university education and high socioeconomic status, which could significantly reduce the representativity of the study. In conclusion, our study supports the role of physical activity in the management of insulin resistance in PCOS women. Due to the fact that physical activity promotes very important metabolic changes, all women with PCOS should be given the general advice to be physically active. However, due to the small size of the Study and Control Groups the role of diet in the treatment of insulin resistance in PCOS cannot be unequivocally stated; the same is true of the role of lifestyle intervention in modulating adiponectin, leptin and resistin concentrations. Moreover, our findings indicated that HOMA-AD might be a promising surrogate marker for insulin resistance assessment in women with PCOS. Therefore, studies in a larger group of PCOS patients are particularly needed to establish the role of HOMA-AD in the diagnosis of insulin resistance and the role of diet and physical activity in treating this metabolic disorder.