Groin pain is a common problem in athletes, leading to significant distress and long periods of absence from sports. Nonsurgical interventions are usually the first line of treatment. However, the most effective intervention for groin pain is unknown and recommendations are scarce.The primary objective of this systematic review was to assess the effectiveness of nonsurgical interventions in the treatment of long-standing groin pain in athletes and to provide some guidance for clinical practice and further research.A search strategy was performed in March 2020 in Pubmed, Google Scholar, PEDro, and Cochrane Central Register of Controlled Trials databases, without any time restrictions. Only randomized controlled trials (RCT) were included for full-text analysis. Data on the patient’s characteristics, duration of pain, study groups, outcome measures results, follow-up time, and return to play time were extracted. The risk of bias in each study was assessed using the Cochrane risk-of-bias assessment tool. Data for analysis could not be pooled for meta-analysis and, as such, a narrative summary of the outcomes was instead performed. The certainty of the evidence was assessed using a variation of the GRADE approach for when a meta-analysis is not possible to perform.Seven RCTs were included for analysis. Most studies were classified as uncertain risk of bias. All studies provided evidence that nonsurgical interventions have significant positive effects and may lead to good outcomes concerning pain, function, and return to sports at previous levels. The certainty of the evidence was assessed to be low using the modified GRADE approach.Despite the low quality of the available evidence, nonsurgical treatments demonstrated efficacy in the management of groin pain and should probably be the initial approach to treatment. More RCTs of high quality are necessary to provide clear recommendations on the most efficient nonsurgical treatment strategy for groin pain. Groin pain is a common problem and a significant cause of morbidity in athletes . Pain isGroin pain is common in sports requiring running, direction changes, and kicking . ImbalanGroin pain usually recovers after a period of rest . HoweverThe primary aim of this systematic review was to evaluate the quality of existing evidence to support the use of nonsurgical interventions in the management of long-standing groin pain. To our knowledge, no other published systematic review limited the evaluation to include only randomized controlled trials nor included all forms of non-surgery treatment. The secondary aim was to provide some guidance on treatment recommendations to help guide clinical practice.MethodsThis systematic review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines . The cliA literature search was performed on PubMed, Google Scholar, PEDro, and Cochrane Central Register of Controlled Trials in April 2023. Only studies published in English were included. There were no time restrictions. The sample search strategy performed on Pubmed consisted of the terms: ((groin pain[MeSH Terms]) OR athletic pubalgia) OR sports hernia[MeSH Terms] AND ((conservative therapy[MeSH Terms]) OR ). Studies for inclusion in this systematic review were screened by title and abstract by two reviewers independently. The criteria of eligibility were the following: the study should be an RCT evaluating the efficacy of nonsurgical interventions in the management of long-standing groin pain. A quantitative outcome measure should be reported, such as the reduction in pain, the percentage of athletes returning to sports at the previous level, and the time to recovery. Studies were excluded if other clinical entities besides groin pain were described as a site of origin of pain (such as femoroacetabular impingement). Studies were excluded if patients had any previous surgical treatment performed for groin pain. References of included articles were screened for other studies that might have been missed in the initial search strategy. Data were extracted into a Microsoft Excel sheet  by two authors. The information collected consisted of the patient characteristics, the diagnosis, duration of pain, type of intervention, study groups, outcome measures, results, follow-up time, and time of return to play.All forms of nonsurgical care were included in this systematic review such as compression clothing, manual therapy, physical agents use, minimally invasive procedures, and various protocols of exercise. The risk of bias of each RCT was assessed using the Cochrane risk-of-bias assessment tool  . Data foResultsSearch ResultsThe initial search retrieved 960 studies. After excluding duplicates, limiting the search to include only RCTs, screening the title and abstract, and excluding evidently ineligible articles, only six RCTs were identified that met the inclusion criteria for this systematic review. Citation screening of the included articles revealed one additional relevant article. Figure Study CharacteristicsAll of the seven selected studies were randomized controlled trials. Five studies were classified as single-blinded RCTs -16 and tA summary of the included studies’ characteristics is presented in Table Summary of OutcomesA summary of the outcomes of included studies is presented in Table Hölmich et al.  describeWeir et al.  comparedAbouelnaga et al.  studied Schöberl et al.  studied Moreno et al.  evaluateComin et al.  studied In the double-blinded RCT by Otten et al. , athleteRisk of Bias AssessmentThe risk of bias detailed assessment of each included study is presented in Table None of the studies was classified as low risk of bias in all of the domains. However, some considerations are important to make. Since all studies were measuring subjective pain outcomes, blinding of participants was essential. However, physiotherapy and minimally invasive interventions make the introduction of performance bias unavoidable since the blinding of participants and personnel to the treatment performed is impossible. As such, most studies were classified as high risk of bias in this domain. Only one double-blinded randomized trial was classified as low risk  because In conclusion, two studies were overall classified as high risk of bias and five were classified as unclear risk of bias. The authors of this review consider that performance bias will always be present in these kinds of studies. Therefore, a lower weight needs to be attributed to this domain when classifying the overall risk of bias across studies. Overall, the risk of bias across studies was considered to be an unclear risk of bias.Certainty of EvidenceBecause pooling of data was impossible to carry out, due to outcome measures being different across studies and differently reported, a meta-analysis was not possible to perform to assess the effect size of the treatment. However, the authors of this review decided to provide a tentative assessment of the certainty of the available evidence adopting an approach previously described by Murad et al. . This meDiscussionThe purpose of this systematic review was to evaluate the effectiveness of nonsurgical interventions in the treatment of groin pain. The literature search revealed a scarcity of randomized controlled trials. The available studies were relatively well designed but had some limitations (some inherent to the nature of the tested interventions) which were possible confounding sources of bias. As a result, the certainty of evidence was assessed to be low. Nonetheless, the analysis of the outcome data revealed that in athletes with groin pain, nonsurgical interventions can lead to significant favorable outcomes concerning pain reduction and return to sports. The body of evidence in this review suggests that an active exercise program is effective in the reduction of groin pain and should be a staple component in any conservative treatment for groin pain. A multimodal treatment, as reported by Weir et al., allowed a faster return to sports compared to active physical therapy; however, there were no differences in the pain measures, percentage of athletes returning to sports, or objective outcome assessment compared to the active treatment group.The addition of shock wave (SW) therapy to an intensive rehabilitation program allowed a faster return to sports and a faster reduction of pain. Interestingly, the group of patients that performed SW therapy had the fastest time to return to sports, compared to the other studies that reported the same outcome (mean 10.5 weeks vs 12.8 and 18.5 weeks ). AlthouWhen conservative approaches fail to improve symptoms, some minimally invasive procedures can be performed. In this respect, the available evidence demonstrated that RFD of the ilioinguinal nerve and inguinal ligament, when combined with physiotherapy, could significantly reduce groin pain compared to steroid plus anesthetic injection and physiotherapy. The magnitude of the reduction of pain outcome measures after RFD was similar to the ones described in other studies testing other conservative interventions. This was a single study and the results of this procedure should be subject to more investigation.Another minimally invasive and recently described procedure for groin pain is intratissue percutaneous electrolysis (EPI). In the only RCT evaluating the efficacy of this procedure, there was a faster and greater reduction of pain in the group receiving the treatment when combined with standard physiotherapy. This was a well-designed study with few limitations and no conflicts of interest. The treatment was well tolerated and there were no adverse events; however, one patient dropped out due to fear of needles, which makes the procedure undesired by some patients. In addition, this was the only RCT on the subject and more data is needed to draw clear conclusions.In the study by Otten et al., wearing high-compression shorts significantly reduced pain in some performance measures and improved symptoms. This study was a double-blinded RCT, with a low risk of bias, providing good evidence that wearing high-compression shorts can be useful for the control of ongoing groin pain for at least a one-month duration. In addition, the intervention had no real contraindications and didn’t affect the athlete’s performance.Although the certainty of evidence available on this subject was graded as low when considering the strength of recommendation for a certain treatment, other factors need to be considered, and not always the intervention with a high grade of certainty is qualified as a strong recommendation. Some of the factors that may impact this assessment are the cost-effectiveness of the treatment, the balance of desirable and undesirable effects, and the patient’s preference. The conservative approaches previously described are relatively cheap, without significant health risks, and usually desired by the patient as an initial approach, and as such, recommending nonsurgical treatments for the management of groin pain takes priority over surgical ones. In the author’s opinion, despite the low quality of the available evidence when considering the mentioned factors, the strength of recommendation for nonsurgical treatments in the management of groin pain in athletes should be classified as strong as the benefits significantly outweigh the risks of the treatment. However, no clear recommendations can be made about the preference for one nonsurgical intervention over another as more high-quality studies are needed to reach definitive conclusions. Nonetheless, the current evidence shows that active physical therapy seems to constitute the base of a successful treatment program.LimitationsThis review has some limitations, the first being that only a few randomized controlled trials were available and included in the systematic review. Furthermore, by discarding all the lower-quality studies, potentially useful information may have been lost on the subject.The second limitation is that the authors were not able to pool the data for quantitative analysis due to the obvious heterogeneity of interventions, outcome measures, and inconsistencies in methodology. Unfortunately, this led the authors to provide only a narrative description of outcomes. The third limitation is that the method of ascertaining the certainty of evidence in the absence of pooled data, although based on the GRADE approach, has not yet been validated. However, we feel this approach provided an accurate grade of the quality of the evidence.More RCTs evaluating the efficacy of nonsurgical interventions for the management of groin pain are needed. The current evidence demonstrates a significant positive effect of active physiotherapy programs, and these should probably be the initial approach to treatment. Minimally invasive procedures, such as the ones described in our review, should probably be tried before more complex interventions are adopted, such as surgery.New RCT studies should try to minimize bias by increasing the quality of the study’s design. However, the nature of some interventions in the field doesn’t allow participants and personnel to be blinded, and, although this can introduce potential bias, performance bias should not constitute a significant criterion to rate lower the quality of otherwise high-quality studies. Newer studies should use comparable single outcome measures when evaluating intervention’s effects, such as VAS, NRS, RTP rate, and RTP time, and standardize the reporting of data so that a meta-analysis can be performed. Function scores are also important to analyze and studies should use validated questionnaires such as the HAGOS.


Age-related cognitive impairment have increased dramatically in recent years, which has risen the interes in developing screening tools for mild cognitive impairment and Alzheimer's disease. Speech analysis allows to exploit the behavioral consequences of cognitive deficits on the patient's vocal performance so that it is possible to identify pathologies affecting speech production such as dementia. Previous studies have further shown that the speech task used determines how the speech parameters are altered. We aim to combine the impairments in several speech production tasks in order to improve the accuracy of screening through speech analysis. The sample consists of 72 participants divided into three equal groups of healthy older adults, people with mild cognitive impairment, or Alzheimer's disease, matched by age and education. A complete neuropsychological assessment and two voice recordings were performed. The tasks required the participants to read a text, and complete a sentence with semantic information. A stepwise linear discriminant analysis was performed to select speech parameters with discriminative power. The discriminative functions obtained an accuracy of 83.3% in simultaneous classifications of several levels of cognitive impairment. It would therefore be a promising screening tool for dementia. This technique assumes that when speaking, we generate an acoustic signal which constitutes a direct behavioral measure of the processes necessary to produce language. The disruption of such processes would result in significant changes in various speech features which, when correctly identified, could be considered as biomarkers of specific pathologies6. The method of automatic speech analysis is becoming attractive because it allows to collect a sample, that is, the acoustic signal from the patient remotely, conveying them minimal costs and discomfort. These characteristics are in significant contrast to the neuropsychological batteries or neuroimaging tests, rather more costly in terms of time and money, and in many cases invasive for the patient.Automatic speech analysis is progressively becoming a promising tool for the screening of different mental disorders8, schizophrenia9, concussion10 or Parkinson’s disease11. Yet, one of the fields in which the search for acoustic biomarkers is becoming particularly relevant is that relating to the discrimination and detection of Alzheimer’s disease (AD) and mild cognitive impairment (MCI)13.The efficacy of speech markers analysis has been tested for the detection of such pathologies as depression14 accounting for between 60 and 80% of cases, a figure consistent across cultures15. In dementia due to Alzheimer’s disease, the insidious onset is generally related to memory complaints as the first symptom. In the course of AD, however, there is a steady decline of cognitive functioning that affects several cognitive domains, including language and speech. With regard to the latter, previous studies have found that AD affects acoustic, temporal, and prosodic features of speech. Speakers with AD present with flat prosody deriving from changes in shimmer, fundamental frequency, and formants17, with a higher number of pauses and voice breaks but with a lower speech rate18, and with very significant alterations in the speech rhythm19. Importantly, the literature using these parameters for AD detection is extensive and proves their great accuracy for group classification21.AD is the most common cause of dementia23. Although heterogeneous, this deficit is usually characterized by language impairments in various tasks, such as verbal fluency, naming, lexical decision24 or changes in spoken language25. Even in cases where there is no direct cognitive deficit of a linguistic type, as is the case of amnestic MCI, difficulties such as a weakening of syntax-semantics integration in complex sentence processing have been identified26. In speech production, people with MCI present with lower speech rate, longer hesitations27, and changes in fundamental frequency and formants28. With automatic analysis, these speech features have proved to be useful in the detection of MCI either by itself18, used in addition to neuropsychological tests29, and in combination with other linguistic measures31.MCI is defined as an objective cognitive deficit of insufficient severity to meet the criteria for dementia, and which does not cause functional problems in activities of daily living33. Thus, the increase in the number of pauses would be a compensatory mechanism necessary to correctly perform on an impaired process34. Syntax planning and semantic relationship between words are also suggested to affect speech rate36. Indeed, the length and the degree of syntactic complexity of sentences are related to speech deficits reflecting an impairment in working memory and attention37. In conversation, speech deficits seem to appear due to the difficulties of people with AD or MCI to comprehend their interlocutor’s utterances, plan their answers, and anticipate turn-endings, reflecting an impairment of executive functions38. Impairments in memory also predict the occurrence of changes in speech, mainly increased frequency and variability of pauses in both story recall39 and autobiographical memory40. It is also proposed that cognitive load influences voice quality parameters42 and such measures of modulation of pitch and amplitude as jitter and shimmer43.Changes in speech parameters of people with AD or MCI would be directly related impairments in several cognitive processes whose performance is compromised in both conditions. Some disturbances in speech rhythm have been related to difficulties in lexical–semantic access, so that they are expected to appear when the speaker presents with difficulties in word-finding44.From the above it follows the type of the task used to elicit oral language is one of the factors directly affecting speech performance in AD and MCI. In fact, based on the comparison of speakers’ performance on different tasks, some studies suggest that tasks with greater cognitive load outperform others in predicting the clinical condition of the patient19, our goal is to improve their prediction by using new tasks that compromise participants’ cognitive resources. In doing so, we use the already explored reading task coupled with a new task on semantic verbal fluency. In reading, people with AD show particularly more pauses and other speech disturbances when exposed to texts with low frequency words, possibly because of the impairment in their semantic memory. Their reading is also characterized as slow and with poor expressive prosody due to encoding difficulties45. With the verbal fluency task, we mean to engage older adults’ resources for several cognitive domains, including lexical access, semantic memory search, attention processes, and executive functions. In addition, compared to most works which perform binary group classification, we aim to obtain a combination of speech parameters that would allow screen between healthy older adults (HC), MCI, and AD. In addition, we will perform an analysis of each of the tests separately and together, so that we can test their efficacy and whether the combination provides an advantage in the assessment.Building on previous studies that used a reading task to develop automatic screening tools for AD and MCI46. The remainder were 24 healthy older adults who formed the healthy control group, and 24 people with dementia of Alzheimer’s type, all of whom were selected from a larger pool of samples to match the participants with MCI in age and schooling.A total of 72 participants divided into three groups were recruited for the study. Of these, 24 were diagnosed with MCI following the criteria of the International Working Group on Mild Cognitive ImpairmentAll participants had to be native speakers of Spanish, with no history of drug or alcohol abuse, no history of psychiatric illness, no presence of severe sensory deficits that would preclude the administration of cognitive tests, and a minimal level of schooling years to have acquired literacy.All participants signed the informed consent form. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments, and the European Union regulations concerning medical research. This research received the approval of the Ethics Committee of the State Reference Centre for the Care of People with Alzheimer’s Disease and other Dementias , attached to the Spanish Ministry of Social Rights and 2030 Agenda.47. Table HC participants and participants with MCI were recruited from attendees of the Psychological Attention Service for the Prevention of Cognitive Problems in the Elderly of the Municipal Psychosocial Support Unit of the Council of Salamanca and the University of Salamanca (Spain). Participants with AD were recruited from the State Reference Center for the Care of People with Alzheimer's Disease and other Dementias, where they were diagnosed by the Spanish National Health Service following the NIA-AA criteria2,69 = 1.096, p = 0.340 or schooling F2,69 = 0.764, p = 0.470. Groups expectedly showed significant differences in MMSE scores F2,69 = 25.144, p < 0.001, which were found between HC and MCI , HC and AD , and MCI and AD .No differences were found between the three groups in age F48.This toolkit includes normative studies on Spanish population for several test. It is structured in two sessions. First one includes Mini-Mental State Examination, Memory Impairment Screening, and verbal fluency. The second one consist of Free and Cued Reminding Test, Trail Making Test, and Boston Naming Test. Furthermore we used additional questionnaires for the assesment of depression and activities of daily living.Participants were diagnosed by a clinician after going through neuropsychological assessment by using Dem-Detect toolkit49, in order to extract a wide set of parameters including acoustic, rhythm, and voice quality features.Speech and language recordings were made using an iPad and a head-mounted condenser microphone, MiC Plus from Apogee. These recordings were preprocessed to eliminate possible background noise and ensure quality, and then analyzed using Praat software, version 6.0The data set obtained from the recordings was preprocessed to increase the quality of the audio files before extracting speech features that could accurately describe the various aspects of the subjects' speech of interest in this study. The audio recordings contained both the participants' and the researcher's voices. Since only the participants' portions of the audio were of interest, the researcher's voice was manually removed after listening to the audio files. The recordings were also analyzed in search of static background noise and unexpected noise caused by sources such as opening doors. Subsequently, the background noise spectrum obtained from the silence regions of the audio files was removed from all files. Finally, all files were normalized, to avoid possible differences due to being recorded with different settings depending on the position of the speaker, the location of the microphone and the distance to the speaker. After the pre-processing stages, the audio files were saved as 16-bit mono-channel .wav files. The original sample rate of 44,100 Hz was retained uniformly throughout all the audio files.50. Previous studies also found intra and intersyllabic pitch trajectories . We expected pauses and rhythmic parameters to be specially affected in semantic verbal fluency task. Furthermore, being the goal of this study to engage cognitive resources, which may be reflected in speech quality and spectral parameters, we also included jitter and shimmer, Acoustic Voice Quality Index (AVQI), Harmonics to Noise ratio (HNR), and band energy parameters (BE). Statistics from several parameters, i.e. mean, median, standard deviation, maximum, and minimum, were also used as speech parameters. A complete list of the features used in this analysis may be found in online Annex Our analysis included those speech parameters that usually prove altered in reading tasks of people with MCI and AD. Thus, we have introduced duration parameters, such as phonation time, speech rate, and both number and duration of pauses. Since fluency and rhythm are pointed out as particularly disturbed in reading, we also introduced articulation rate and syllabic parameters . Spectral analysis parameters, such as fundamental frequency, formants and their bandwidths, asymmetry and center of gravity, are also usually altered in MCI and ADSince we expect the changes in speech parameters in each of the tasks to be due to the involvement of different processes, the audio files have been analyzed separately. Still, for exploratory purposes, the same speech parameters have been extracted from each of them.In order to assign the participants to their respective group, each of them went through a cognitive assessment lasting three sessions of approximately one hour each, usually conducted one week apart. Session one and two consisted of anamnesis and DemDetect Toolkit, as described in the instruments section, while session three was used for additional tests if necessary and participation in other studies. This assessment was carried out regardless of wether the participant had a previous diagnosis made by the health system or not, in order to confirm and characterize their level of impairment.Don Quixote. In our previous study50, we made a strong case for the choice of this text excerpt, allowing to control for semantic load due to the combination of high-frequent and low-frequent words, complex syntax, and relative encyclopedic control.In addition to the assessment, participants were asked to perform two tasks that were recorded. The first consisted of a reading task, based on the reading aloud the first two sentences of the novel Parcheesi tiles are colored…” and completing it with four words for expected colors: “green, yellow, red, and blue”. Parcheesi is a very popular game in the Spanish culture and is therefore part of the general encyclopedic knowledge. Thus, the task required participants to retrieve from their memory both the encyclopedic knowledge about the four colors of the Parcheesi tiles (semantic load), and the corresponding lemmas for these highly common color names . We predicted that the advantage of this task over a classical semantic verbal fluency task relied on significantly reducing the variability of participants’ responses due to the limitation of the expected elicitations. We made sure that all participants were familiar with the game. Elicited utterances were analyzed regardless of whether the answers  were correct or not.The second task consisted in orally repeating the sentence "Statistical analysis was conducted using IBM SPSS Statistics for Windows, Version 26.0. The speech measures from both tasks were subjected to linear discriminant analysis with a stepwise method for the inclusion of variables. Diagnosis, i.e. HC, MCI or AD, were used as dependent variables. The analysis included a leave-one-out cross-validation.In addition, we will perform an analysis of the two tasks separately using the same procedure in order to compare the performance of the classification using just one task.2 = 135.181, d.f. = 24, p < 0.001) contributes to discriminate between the three groups, finding a more pronounced difference between HC and MCI  specifically contributes to differentiate AD group from the rest.Discriminant analysis yielded two functions. Function 1  and Function 2 . Group centroids for these functions can be found in Table First, the discriminant analysis using the features extracted from the parcheese task yielded two functions: Function 1  and Function 2  whose group centroids are found in Table For its part, in the reading task, we obtained two functions: Function 1  at the same time. The literature on the detection of these entities is extensive, but seems to coincide in achieving predictive algorithms with 90–95% accuracy for AD, and a lower accuracy of 75–85% for MCI51. Here, for a multiclass classification, we obtained a much lower accuracy of 66.7%, which is still higher than that of the new proposed task. It is with the combination of the two tasks that we observe that the classifier shows overall good results, improving the performance of the reading alone and allowing us to classify the three groups. We believe that this opens a door to continue exploring new tasks based on the available knowledge about the cognitive deficits shown by the target entities to be evaluated. This being applicable both to those proposed in this study and to the exploration of other pathologies with this same method of speech analysis. Some possibilities for MCI and AD are the aforementioned autobiographical recall, which would account for episodic memory deficits, or tests aimed more directly at engaging executive processes such as letter-number sequencing.As a way of verification, we tested the performance of the speech tasks separately. In this sense, we were already building on our previous work, which focused on reading. Thus, we had obtained in binary classifications HC vs AD an accuracy of 92.4%39. However, there is a social need to develop and carry out screening of more advanced stages of cognitive impairment, since nearly 40% of aging population with such impairment remains undiagnosed62.Arguably, the fundamental objective of speech-based analysis in cognitive aging is to differentiate MCI from HC and, furthermore, to identify those profiles which more likely will evolve to AD. More and more experimental studies are focusing on this objective in recent years51, applications63 or even phone calls64. Although the sample for this research was collected in the laboratory context, it is easy to transfer the same speech collection protocol to other contexts without any loss of quality, even possibly doing so in noisy environments65. Importantly, the available evidence shows that cognitive screening based on speech collection and assessment is accepted and positively valued by users due to the simplicity of its administration67. Other practical advantages of this technique, like the objectivity of the evaluation process, the possibility to reach a wide population sector due to the widespread use of technologies , and the consequent low burden for the healthcare system, can be highlighted68.One of the most outstanding potentials of the results of speech analysis in cognitive aging lies in the possibility to perform such screening by means of electronic devices69. On the other hand, we must bear in mind that given the number of parameters included in the joint analysis of the two tasks, it will be necessary to continue testing on larger samples.One of the limitations of this study relates to the cultural constraint of the elicitation task. As described above, the semantic verbal task is strongly based on the assessment of culturally conditioned knowledge of the Spanish society. Therefore, it might not be generalizable to many other contexts. Although Parcheesi is a universally known game, it can be much less popular in other cultures and it will be complex to adapt it as a normative task to different contexts. Moreover, it should be considered that although all participants of this study knew the game, it could be criticized that the mere knowledge of it does not imply either that they knew the exact colors or that, even knowing them, could produce a quick response unless the level of familiarity was high. Future research should explore whether the task is performed correctly, how many colors the participants are able to say, and if they are those corresponding to the game. This process could also be automated by means of automatic speech recognition systemsThis study shows that automatic speech analysis can be used in the assessment of MCI and AD in cognitive aging. It particularly proves that research on speech-based detection of dementia (or any other disorder) should involve tasks that take into account the critical cognitive impairments of the target groups. This assumption led us to include and test a new elicitation task considering cognitive alterations observed in aging speakers when performing verbal fluency tests. As a result, we could obtain a good classification accuracy. This result invites us to continue its development in tests with larger samples and to consider the possibility of performing a clinical validation to consolidate it as a screening tool. We also expect to improve it by exploring new tasks compromising other cognitive domains in older people with MCI and AD. We believe that correctly classifying the three groups of older adults  makes this combination of parameters a reasonable option for use in the clinical settings, given that it addresses several needs without diminishing the sensitivity to the MCI stage, i.e., the earliest and most likely to be undiagnosed in cognitive aging.Supplementary Information.


The power sector is one of the most important engineering sectors, with a lot of equipment that needs to be appropriately maintained, often spread over large areas. With the recent advances in deep learning techniques, many applications can be developed that could be used to automate the power line inspection process, replacing previously manual activities. However, in addition to these novel algorithms, this approach requires specialized datasets, collections that have been properly curated and labeled with the help of experts in the field. When it comes to visual inspection processes, these data are mainly images of various types. This paper consists of two main parts. The first one presents information about datasets used in machine learning, especially deep learning. The need to create domain datasets is justified using the example of the collection of data on power infrastructure objects, and the selected repositories of different collections are compared. In addition, selected collections of digital image data are characterized in more detail. The latter part of the review also discusses the use of an original dataset containing 2630 high-resolution labeled images of power line insulators and comments on the potential applications of this collection. The main idea behind this paper is to collect datasets related to power lines which are dedicated, among other things, to improving the maintenance processes. The article tries to fill the gap in the field of datasets usable for training deep learning models for the power industry. The overview provided here could be used as a source list for other researchers interested in training their own deep learning models with open source datasets.Many researchers have dedicated their time to providing powerful algorithms and applications for the power industry. They aim to provide solutions for monitoring and supporting maintenance processes, and the current boom in deep learning methods has made this possible. However, such an approach usually requires a large amount of good quality and well-labeled data to be exposed to the algorithm training process . Such data collections are the ones of interest for this paper. What is reported by many researchers who prepare and share their training datasets  is thatPower lines are a specific object that generates additional complications during data collection, the most problematic of which are safety concerns ; private property and permits ; variability in infrastructure , environmental factors , and natural events .Equally important is the precise reference information for each data sample. Often it is quite easy to depict many parts of a power line, but later they must be carefully studied and, as in the case of detection tasks, require precisely marked classes on each image. This usually triggers a long process of dataset preparation and review, which for some advanced or unique components may depend on external domain expertise.Data fusion and integration: Researching methods to combine data from multiple sensors and sources to create more informative datasets. Integrating data from different types of sensors, such as visual cameras, thermal imaging, and acoustic sensors, can provide a more comprehensive understanding of power line conditions,Real-time analysis and decision making: Advancing real-time data analytics to enable proactive decision making and predictive maintenance for power line assets. This includes developing algorithms that can quickly process large amounts of data to identify potential problems and optimize grid performance,Automated data collection: Developing advanced techniques for automated data collection from power line assets using drones, satellites, LiDAR, or other remote sensing technologies. Automation can reduce human intervention, improve data coverage, and enable more frequent data updates.Nowadays, the field of power line dataset generation is evolving and researchers are facing several challenges to improve data quality, accessibility, and utility. In our view, the most important current research challenges are:Current research, e.g., , provideHowever, there are many other researchers who, in addition to presenting an already working algorithm, also emphasize the very high importance of the dataset and the high difficulty of its preparation, and suggest the necessity of obtaining more training material. These postulates can be found, among others, in , who desFortunately, instead of performing a costly and demanding dataset development every time images are involved, one could choose to adapt one of the existing sets. This paper aims to review the most productive collections that could be productive for researchers and companies interested in publishing algorithms for power line industry applications.First, we checked the background of this topic and decided to analyze the popularity of this subject. The following terms were investigated to check their popularity in terms of the number of indexed journal and conference publications and their impact (measured by the number of citations): datasets for power lines, for conductors (or wires), for power line insulators, or for detection or for classification, and for the same keywords. This should be interpreted with caution since the terminology in the field varies from researcher to researcher , but it still indicates a rapid increase in the field and its development.The investigation revealed that the number of papers discussing the datasets for the power line equipment has exceeded 220 in the last few years. If we also include in the search the number of papers dedicated to the widespread applications of these datasets, such as classification or detection tasks for the power lines, conductors, or insulators, we obtain more than 580 papers published in 2022 alone. The summary of these numbers is shown in The following part of the paper consists of two subsections. Although it would be tempting to provide an exhaustive list, this is not possible, as new sets are being released every day. So we decided to focus on the most popular sets, with one additional condition. This is the availability of the set to be downloaded and the possibility to use it for research.A number of the listed image batches could be used for classification problems ,33,34,35robust defect analysis for power line equipment using convolutional neural networks (CNN), achieving, with this large evaluation dataset, up to 98% accuracy ;preventing cascading failures of the grid ;detecting power lines themselves using CNNs ,38,39, otransmission tower construction inspection  of 72.45% from satellite imagery , or sepafor sub-element diagnostics, such as conductor detection purposes (with AP of 0.729 ) or insuSome of the reviewed collections have been in the public domain for several years. This allows us to examine their impact on the field and verify that they really aim to provide working algorithms. We have listed the examples of such proofs of concept and published results in Applications that use images collected by UAVs are also popular because they allow the development of a well-performing algorithm. Another example is the scale enhancement pyramid network, which achieved an AP score of 81.5% for small object detection . It is aAnother large group of reported applications deals with the detection of power line insulators, e.g., from aerial images (with an mAP of 0.90 ), indoorauxiliary equipment of overhead power lines:–clamps for attaching wires and auxiliary lines;–accessories intended for connecting clamps with insulators;–accessories for suspending insulator chains on poles and connecting multi-row chains;–protective equipment fixed at both ends of the insulator chains, designed to spread the electric field strength;–power line spacers used to fix bundle wires and ensure a constant distance between them;–tuned mass dampers (Stockbridge dampers);–protective marking ;–de-icing and anti-icing equipment;detection of objects colliding with high-voltage lines:–branches and trees (problem of transmission corridors);–stork nests on poles.The essence of this study is detailed in Size: the collection should provide enough data to allow accurate power line diagnostics. The more data, the better the chance of detecting damage. However, for the mentioned set , its siDiversity: The collection should include a variety of data, different power line conditions, and address realistic scenes. In this way, it should be possible to identify problems in a variety of conditions, which is crucial for effective power line monitoring. In the mentioned set we have emphasized different groups of insulators and their damage have been collected .Data quality: The image material in the selected set should provide the highest possible resolution in its recording, which later will help the precise marking process. This is one of the most important aspects of a well-prepared collection, while incorrect or inaccurate annotations can be misleading.Generic nature: The method of registration partially disqualifies the usefulness of some sets for applications in diagnostic solutions based on air flights. In the promoted set, the acquisition was performed from the air, which refers to similar recordings during a scheduled diagnostic flight.Developing a domain data collection, which was the main goal for this review, is rather difficult, especially when it should target power industry equipment. Such a collection should allow one to deal with a narrow spectrum of problems, aid dedicated algorithm and application development, and encapsulate a narrow field of knowledge. Since the most interesting elements of the power line infrastructure are objects located in its vicinity, it often requires the data acquisition process to be realized on an upper section of the power poles. Training data recorded from the ground would be very different from that recorded during diagnostic flights. This creates an additional difficulty in the process of collecting good quality samples, as it usually necessitates flying a helicopter in the vicinity of the power line. Such an approach significantly increases the cost of dataset development and often excludes smaller organizations and individuals from the market. Another barrier to the creation of such domain datasets is the need for the expertise required to classify and assess damage to elements of towers or other power line equipment after data collection. As part of the review, the current state of available collections, their quality and usefulness from the perspective of power line diagnostics automation has been presented. In our opinion, the most valuable among the presented collections is the set from , althougThere is one more special set that we would like to draw your attention to: the collection of images of an insulator taken outdoors in varying lighting conditions with additional laser spots . The fulTo evaluate the effect of lighting on the efficiency of the computational methods, the images were taken at different stages, at different times of day, and in different positions . The position of the camera and the insulator were not changed during image acquisition. Examples of images taken under different lighting conditions are shown in In order to obtain information about the variability in illumination on the surface of the insulator, the research had to be carried out outside the laboratory under natural lighting. The images of the insulators installed on the power lines are characterized by a great depth of image, caused by a considerable distance from the background elements. In order to achieve a similar effect, an aluminum structure has been constructed that allows the installation of various types of insulators with the possibility of smooth angle adjustment from 0 to 90°. The images were taken from a distance of 5 m using a Canon EOS 5D Mark II camera with Canon 50 mm f/1.8 and Tamron AF 28-300 mm lenses. During the registration, the light intensity was also recorded using the measuring instrument Testo 435-4 and the Testo 0635 0545 measuring instrument (lux probe for illumination level measurement). The change in intensity during the measurement was in the range of 632 to 45,479 lux. A dataset was prepared to verify the author’s method of detecting insulators using a high-power laser that generated a grid of points. In total, the collection contains 2630 images, with and without visible laser spots.The first application of the presented image collection was the development, testing, and evaluation of methods for detecting power line insulators on digital images. In order to accelerate the work on the algorithm, the process was supported by laser light, which allowed the area of the object search to be significantly reduced and the detection to be significantly speeded up. At the same time, other research aimed to develop new methods for detecting power infrastructure objects on high-resolution images in scenes with varying backgrounds. methods of detection and location of insulators in images;preparation of classifiers of technical facilities;methods of laser spot detection on digital images made outside in variable lighting conditions;methods of assessing the condition of the insulator’s surface, or other deep learning algorithms, in particular, convolutional neural networks, generative adversarial networks, or deep belief networks.In addition, the presented dataset can be used to develop, verify, and compare:The presented review should be considered a source of such image sets as the ones reviewed, which could be used for the development of automated solutions for the power line industry, or as a blueprint for the process of preparing one’s own dataset.A good example of such a collection is one of the most extensive of the presented datasets , which, With the rapidly growing number of unmanned devices equipped with high-resolution cameras, we are also seeing a significant trend in the number of datasets built from such imagery (described in Most of the collections presented here are based on single modality data, in most cases an image from a camera or points from LiDAR sensors, which may not be sufficient for industrial solutions. Increasingly, however, the results of correct object detection and classification are based on data fusion from a group of various sensor modalities, such as VIS, IR, NIR, UV, and point clouds. Such datasets ,55 are cIn the long term, the economic implications of the study conducted will allow the development of tools to optimize the planning and maintenance of critical infrastructure through the early identification of areas of increased degradation, which will directly lead to an increase in the life of the infrastructure. Undoubtedly, in the short term, the implementation of advanced diagnostic technologies may require significant investment, which is a challenge for operators and energy companies.


Format for Formulary Submissions, Version 4.0, is the next iteration of the Format, which was first released in 2000. Version 4.0, developed by pharmacists from health plan, manufacturer, and academic perspectives, provides updated recommendations on acquiring and evaluating clinical and economic evidence to inform formulary and medical policy decisions. It also includes new guidance related to emerging special topic considerations such as biosimilars, specialty pharmacy products, and companion diagnostic tests. Version 4.0 has been modified to improve the usability of the Format, with clarifying guidance related to logistical considerations such as a recommended time frame for implementation of Version 4.0, as well as dossier updates and ongoing communication between manufacturers and health care decision makers. The Format should be used as a framework for ongoing evidence-based dialogue between manufacturers and payers. The evolving health care landscape will require new levels of collaboration and communication among key stakeholders to successfully navigate the challenges of this new environment. The Format provides a framework to support these critical interactions related to product value by facilitating an evidence-based, transparent approach.Managed care pharmacists are increasingly presented with complex considerations related to prescription drug formulary management. As prescription drug spending soars, and new effective, but expensive drugs rush to the market, pharmacists and other health care decision makers must evaluate a myriad of important clinical and economic considerations in determining the relative value and, subsequently, the appropriate placement of a product within a formulary. The AMCP  As such, traditional pharmacy roles have evolved to incorporate complex considerations related to evaluating and balancing important attributes such as treatment benefit and risks, cost-effectiveness, and affordability.The role of the pharmacist in managed care settings has evolved considerably in recent years. This is in part because of a flood of new, effective, and often expensive interventions that require careful analysis for developing and managing a viable pharmacy benefit. The financial impact of these new products is considerable, contributing in part to a 12.2% increase in national prescription drug spending in 2014—the largest increase since 2002.4 These initiatives serve to provide guidance to health care decision makers (HCDMs) and patients regarding important considerations related to assessing the value of health technologies. While these initiatives represent a positive step to encourage a more focused dialogue regarding the value of health technologies, they also highlight, as noted by Neumann and Cohen (2015), that “value is an elusive target, and there’s no consensus about what dimensions should be taken into account.”3This enhanced focus on deciphering the inherent value of new products is reinforced by the recent proliferation of initiatives from a number of health care organizations to develop value frameworks with the objective of providing a more rigorous and comprehensive assessment of value when considering the adoption of new health technologies, including new pharmaceutical products.Format for Formulary Submissions has served as a benchmark to guide drug manufacturers regarding important payer evidence requirements for evaluating new technologies for formulary and medical policy consideration. The Format serves to improve the timeliness, scope, quality, and relevance of clinical and economic information provided by manufacturers to HCDMs, as well as to streamline the evidence acquisition and review process for decision makers. Given that value is in the eye of the beholder, the Format does not prescribe a specific formula to calculate the overall value of a health technology. Rather, the Format endeavors to provide guidance on the key clinical and economic evidence requirements that serve as the fundamental components of determining value. Thus, one of the intended benefits of the Format is to improve the credibility and transparency of the process, which is aligned with the core values of the Academy of Managed Care Pharmacy (AMCP).Since its initial release in 2000, the AMCP Format as a top priority in 2015. The Committee solicited input from AMCP members and revisited content considerations noted since the previous update (Version 3.1), which was published in 2012.5 Based on this input and a detailed review of relevant developments in the payer evidence landscape, the Committee moved forward with a full revision, forming 3 work groups composed of committee members and external contributors to address updated considerations regarding clinical evidence, economic evidence, and key logistical considerations related to the Format. A draft of the Format, Version 4.0, was released for public comment in December 2015. The Committee carefully considered the input received and made revisions where appropriate. Subsequently, the final draft was reviewed and approved by the AMCP Board of Directors in February 2016.Given the evolving health care landscape and enhanced focus on discussions of value, the Format Executive Committee, composed of AMCP members representing a mix of health plan, manufacturer, and academic perspectives, identified a full revision to the Format, Version 4.0, we have endeavored to address evolving considerations in the health care environment, including considerations related to biosimilars, medical devices, comparative effectiveness research, and companion diagnostic tests, to name a few. Guidance on logistical matters related to updating dossiers, the challenge of providing preapproval evidence, and ongoing communication between manufacturers and HCDMs is provided as well. Some critical updates to the Format include the following:With the release of the Format for drugs, tests, and devices; biosimilars; and assessing heterogeneity of treatment effect.Detailed and clarified guidance for handling of contemporary content topics such as comparative effectiveness research; use of the Inclusion of guidance related to evidence requirements for companion diagnostic tests.Comprehensive guidance added for specialty pharmaceutical product information, including handling and distribution requirements and restrictions; appropriate settings; supportive care services; and medical benefit considerations, such as coding.Format with biosimilar products, including comparative data requirements relative to reference products.Specific guidance related to using the Restructured Section 3.0  and Section 5.0 , with additional guidance provided on recommended evidence components for each section.Format to more closely align with updated best practices published by the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and Society for Medical Decision Making (SMDM) Modeling Good Research Practices Task Force for economic models.6Revision of the economic evidence section of the Incorporating new guidance on budget impact models as unique deliverables in addition to cost-effectiveness analyses as a component of the overall economic evidence dataset.Guidance on modeling considerations for biosimilars and specialty products.Updated guidance on updating dossiers and handling dossier requests before U.S. Food and Drug Administration approval.Format, Version 4.0.Implementation time frame for adoption of the Format, with the provision of links to publications or PubMed where available.Revision of many references throughout the Format, our primary objective was to provide updated guidance to HCDMs and manufacturers that enhanced the clarity, transparency, and usability of the Format, while reinforcing the role of the Format in facilitating ongoing scientific dialogue between payers and manufacturers. Additionally, we wanted to ensure that this new version addressed important new developments in the marketplace. One challenge in providing this guidance is the recognition that our audience is comprised primarily of 2 disparate groups: dossier developers, such as manufacturers, medical writers, and consulting groups, and dossier consumers, who are primarily HCDMs involved in evidence assessment and formulary management. We have attempted to target an appropriate middle ground in developing this updated version. By outlining and describing the key evidence components that are relevant to a formulary or medical policy decision, we hope to reinforce a multifaceted approach to evaluating new technologies, while leaving the final value determination to the ultimate decision maker. On the other end of the spectrum, we have developed specific guidance to dossier producers regarding the content and format of a dossier, while relying on existing standards related to the more technical considerations of value evidence generation and communication. With this approach, we hope that the Format will meet the needs of a broad range of perspectives, while providing clear direction to related resources that may offer additional relevant technical detail as required.In developing this new version of the Format to be viewed as a vehicle to enhance evidence-based communication between manufacturers and HCDMs. Substantial, ongoing communication throughout the evaluation process is a critical success factor in promoting credible, transparent discussions related to product value. We encourage HCDMs to use the unsolicited request process as a means to engage manufacturers in these important conversations, and we encourage manufacturers to provide clinical and economic evidence in a consistent, transparent framework as represented by the Format. We view the Format as offering a clear, shared vision of the requirements to facilitate the collaboration necessary between HCDMs and manufacturers to support appropriate and evidence-based product evaluation.Ultimately, we want the 7 HCDMs are encouraged to revisit and appropriately revise formulary decisions based on the availability of new and compelling evidence. As such, ongoing communication between manufacturers and HCDMs as the value evidence evolves is a critical component to the process.It is important to emphasize that the scope and context of communications between manufacturers and HCDMs should evolve over the product lifecycle as new evidence becomes available. While launch-timed dossiers may rely to a greater extent on modeled projections based on clinical trial evidence and reasonable assumptions related to market dynamics and product uptake, new evidence describing the actual use and effect of the product in a real-world setting should be developed and used to inform formulary management or medical policy criteria across the product lifecycle. Ongoing generation of real-world evidence serves the important purpose of further defining and validating claims related to product value.Format, we appreciate the input provided by our committee members and external contributors and, particularly, the outstanding feedback we received during the open comment period by HCDMs, manufacturers, and other interested parties. This feedback provided useful confirmation of key issues and helped us identify areas that required additional work. We hope the result is an updated version of the Format that provides enhanced clarity, transparency, and usability to HCDMs and manufacturers alike. The Format should stimulate relevant, evidence-based, ongoing communication among the key stakeholders in the process and support the development of informed, rational formulary decision making.In revising the


To identify how quality and design of streets impacts urban stress.Few studies have comprehensively addressed environmental factors affecting stress in urban public spaces. However, a remarkable portion of our everyday life is spent in public spaces, particularly streets.n = 16) aged 20-30, with an equal number of men and women who were generally healthy and had normal stress levels. Participants were asked to wear an electroencephalogram (EEG) headset, walk different streets, and answer the Perceived Restorativeness Scale (PRS) and urban design qualities questionnaires.This study seeks to evaluate the effect of three types of streets as major public spaces on stress. These include a street with the dominance of green spaces (A), a motorist-oriented street (B), and a pedestrian street (C). For this purpose, we selected a group of participants (According to the results, participants experienced the highest stress in street type B and the lowest in type A.Green space and vegetation, a sense of security, privacy and coziness, climatic comfort, and safety of space had the most positive effect on stress reduction. Whereas noise pollution, vehicle traffic, and crowdedness were the most critical factors of stress. Finally, our findings suggest that the component of green space has a more significant effect on stress reduction compared with the elimination of vehicle traffic. World Health Organization (WHO) has defined health as complete physical, mental, and social well-being beyond the mere absence of disease . These dIn today’s modern society, stress is one of the factors of health that potentially underlies many diseases . Stress This study seeks to measure the effect of the different dimensions of street design on citizens’ stress levels and present a novel perspective on how stress can be controlled in public urban spaces.Various factors in public spaces, such as noise pollution, visual pollution, air pollution, crowdedness, social conflicts, decreased sense of belonging, scarcity of green space, and lack of security, tend to create psychological tensions and negatively affect people’s physical and mental health . These pAs a large part of our everyday life is spent in public urban spaces, their quality and design may directly impact stress levels. The literature on the relationship between public urban spaces and stress is still at its beginnings. Many studies in this field focus on the impact of exposure to natural versus built environments  and muchThe majority of the studies of mental health in urban settings have been conducted in developed countries; however, many of the most stressful cities in the world are located in undeveloped or developing countries. It seems the issue of mental health is more serious in these countries. This study aimed to evaluate the urban stress in Tehran, a city in a developing country, Iran. According to the results of research by Zipjet Company in 2017, Tehran is named the 6th most stressful city in the world, which can be partly attributed to the quality of public urban spaces.Hans Selye first used the term “stress” in 1935 to explain tension factors in living creatures . Since tThe environment has historically been regarded as a factor that influences human health. In other words, our quality of life depends on the quality of the environment in which we live . Today, There are two theoretical explanations for restoration environments: First, stress recovery theory is concerned with restoration from stress, which occurs when an individual is confronted with a situation perceived as demanding or threatening to well-being. Ulrich’s theory proposes that natural environments promote recovery from stress, while urban environments tend to hinder the same process . Second,Although many stress and environmental studies have focused on green spaces, public urban spaces are not confined to green spaces. The typology of urban public spaces is a complicated issue that has been addressed by many scholars from the viewpoint of form, function, sociocultural, and socioeconomic aspects. The most prevalent method of typology is based on urban forms. Despite some theoretical differences, most proponents of this typology have recognized streets and squares as two major types of urban space. In urban design, the most crucial component of a successful public space is its qualities ; being green is only one of these qualities. A glance at the literature in this field indicates that researchers have dealt with only several dimensions of public spaces that might affect stress. There seems to be a need for a comprehensive view of the factors of urban public spaces that influence stress levels. In this section, we shall attempt to analyze different urban stress factors and propose a comprehensive model of stress factors in urban spaces.Research findings suggest that crowded environments likely increase tensions . In otheClimate change is another issue that may directly or indirectly affect human mental health. Violence is more prevalent in warmer cities, and exposure to excessive heat increases secretion of stress hormones . The exiResearch into the effect of soundscape on human health has demonstrated that long-term exposure to traffic noise and other noise pollutions could increase stress hormones . On the Ninety-one percent of the world’s population is deprived of clean air . Studies suggest that negative personality traits are more prevalent among inhabitants of areas with polluted air. Smells are an important factor in air pollution . AnalysiIn addition to noise and air pollution, the adverse effects of visual pollution on mental health have recently become the subject of research in this area . Visual Colors affect the secretion of hormones and, thus, contribute to different emotions, behaviors, and personality traits . Colors Another factor that affects stress is light and brightness . In contHumans have an innate fear of the unknown. As they grow up, they get to know the signals of a sense of security. As long as an individual does not feel secure in an environment, their body is prepared to face any strange thing; but when the sense of security is felt, they achieve peace of mind, and the stress mechanism is deactivated . Fear ofThe human mind is more at peace when others are present. In other words, belonging to a group and receiving social support increases the chances of survival and achieving one’s goals and helps to relieve fear and anxiety . As humaCohesion and integrity allow for a better perception of environmental stimuli, which could reduce tension . LegibilSport and physical activity positively influence stress levels and one’s personality traits and self-esteem apart from duration and intensity, gender, age, and health status . ExercisUrban environments with a mix of land uses  are associated with lower levels of psychological distress and improved mental health outcomes, compared to environments with a more segregated land-use pattern . Land usLiving on the upper floors of buildings is associated with less physical activity, behavioral problems, respiratory diseases in children, neurosis, and social isolation . People The scale of space can also influence mental health. Large-scale squares and streets with less complexity of details in the facades are likely to increase stress, and this is an emphasis on the advice of planners and architects such as Jan Gehl, who are opponents of building less-detailed spaces with nonhuman scales . The larAs mentioned before, the ability to control space affects stress reduction, and this is precisely the definition of flexibility quality in urban design. When you need to change the space and face limitations, you will gradually experience psychological reactions such as stress, anger and aggressiveness, helplessness, and ultimately, disappointment. Flexibility can help to reduce stress by creating spaces that are more adaptable and responsive to the needs of individuals . When inGiven the inverse correlation between happiness and perceived stress , it seemAs discussed above, each study in the literature has mentioned one or more stress factors, which are summarized in An analysis of the above items would disclose that the main stress factors are personal and environmental. Environmental factors can be divided into three categories: space-creating elements, social quality, and environmental quality. The abovementioned studies have used various instruments for measuring stress depending on the nature of the studies. The most common method is to use self-report questionnaires such as Holmes and Rahe Stress Scale, Cohen Stress Scale , and theMuch of the focus on gray versus green has been virtual while real-world experience is quite different and much more complicated. This study seeks to identify and use a proper combination of the existing instruments to evaluate environmental stressors within the real environment and determine which type of urban street is most effective in reducing stress levels.This research is a cross-sectional study, and the possibility of change in chronic stress is very low in this type of study. Therefore, acute stress and perceived stress have been emphasized.As a pilot study and due to financial constraints, we used a sample of 16 participants. To homogenize the sample and control the effect of individual factors , we selected a group of students in the age range of 20-30 years, with an equal number of men and women. We invited Tarbiat Modares University’s students to participate in the test. Considering the effect of health status and stress levels on the test results to assess the general health status of the participants, they were asked to complete the General Health Questionnaire (GHQ). The GHQ is a self-report screening tool used to detect possible psychological disorders . Stress Each participant was asked to wear the EEG device and walk over the specified path while the research team followed them within a distance of 8-10 m so that they would not affect the participant’s behavior. The team exactly recorded their actions and reactions. After the walk, they were asked to fill out two questionnaires, that is, PRS and the questionnaire for evaluating the environmental qualities affecting stress. Each participant walked on three designated streets , and the attendance order on the streets was the same for all participants.We performed our experiments in the middle of the week to ensure that people were doing their everyday activities and tried to minimize the varying effect of time on the participants’ experience by performing the experiments at a fixed time in the afternoon in July.Ranking of stressors in Tehran indicates that air pollution, noise pollution, and traffic are among the most important environmental stressors . According to the results obtained by Zipjet Company in 2017, Tehran ranks sixth among 150 cities in terms of stress level. Factors of stress in Tehran have been evaluated in Given the city’s status in comparison with other cities of the country, this study focused on the physical-functional center of Tehran, which is representative of its different districts and has the highest density of people’s presence. After examining the typology of streets, the most important streets in terms of stress factors were identified.The street types selected in this study include a street with green space and appropriate sidewalks (Type A), a car-dominated street (Type B), and a pedestrian street (Type C). An equal stretch of the three streets was specified so that the participants could spend equal time in all three streets (disregarding their speed). It is one of the most popular streets in Tehran, which has good recreational facilities. The central lane of this street is a green path for pedestrians and bikers. The park, located on the edge of this street, contributes to the area’s visual beauty and air quality. The water canal inside the central green pedestrian path and the chanting birds are invaluable features that are quite attractive to users see .As one of the main central streets of Tehran, this street acts as a hub in the communication network and has a high level of traffic and noise pollution. The concentration of different commercial and administrative uses, book publishers, and the university attracts many people from all over the city see .This pedestrian street is a historical axis that is now a completely pedestrian area with considerable tranquility. It is famous for women’s bags, shoe stores, and other appealing uses such as floristry and restaurant see .Due to the lack of access to portable multichannel EEG, we were confined to using single-channel EEG devices. We used a Neurosky single-channel EEG device in our experiments. Despite its relatively low price, its efficiency in recording the user’s mental status has been validated . The acctotally disagree) to 7 .The PRS questionnaire developed by The score of the questions that measure the environment’s negative effects is calculated inversely, and the final score is calculated. A higher score indicates a higher healing potential. The reliability of the questionnaire was confirmed through a Cronbach’s α value of .82.never) to 7 (completely). For example, participants were asked to rate questions such as “How safe do you feel on this street?” To what extent do the heights of the buildings on this street make you feel relaxed?  as presented in p = .005) and Type B  ranked second and third, respectively.The Friedman test revealed a statistically significant difference between the mean values . According to The mean values on the subscales of being away, fascination, coherence, and compatibility are presented in The reliability of the results from each street is assessed by calculating Cronbach’s α using SPSS software. The resulting Cronbach’s α values for Type A, Type B, and Type C streets are .79, .81, and .80, respectively, indicating good internal consistency of the questionnaire responses in each street type .According to the study, the mean values of participants’ responses for each quality are presented in p value of .001. To further investigate these differences, pairwise comparisons were performed using the Wilcoxon test (p = .06), art (p = .2), land use (p = .097), density (p = .94), or building facades (p = .14) across the different street types.The positive impact of different street types on participants’ relaxation, as measured by the mean values, is presented in xon test . The WilA pairwise comparison of the mean difference for each quality in street types by the Wilcoxon test is presented in This study investigates the provocation of stress in different urban street types and the factors involved. In contrast to previous studies , the parThe participants believed that heavy car traffic, noise pollution, crowding, and air pollution in Street B were stressful, and this has also been confirmed by previous investigations .According to the questionnaire results for evaluating the environmental qualities affecting stress, there is no significant difference between Types A and C, whereas the PRS questionnaire indicates that Type A has a more significant potential for relaxation. First, this highlights the importance of methodology in the studies. If we examine the subjects’ selection among the three street types in three methods , we can find participants whose ratings turn out to be different through each method . Therefore, to measure environmental stress, it is necessary to study the environmental perception process and the functions of the brain because it may be the case that a factor neglected in the questionnaire is of greater importance to the mind....it is necessary to study the environmental perception process and the functions of the brain because it may be the case that a factor neglected in the questionnaire is of greater importance to the mind.Using multiple methods for environmental quality evaluation is often neglected in majority of studies , but ourSecond, given the characteristic feature of each street type , these two types are not equal. Thus, the lack of significant difference between these types seems to be because the components were not weighted. The question is: Which components are more effective in reducing stress? This highlights the importance of studying how influential factors affect each other. From the PRS results of these two street types (A and C), we can conclude that natural elements are more effective in stress reduction, and this is in line with previous findings .In contrast to some of the previous studies , this stTherefore, it can be argued that green space and vegetation play a more critical role in encouraging people to perform physical activity. Type B provoked the highest stress levels because of lower environmental qualities, notably noise pollution and car traffic. We also expected that eliminating motor vehicles from the urban space (Type C) would play a key role in reducing stress, but the results obtained for Type A suggested that this measure alone was insufficient. Previous studies in the literature mainly focused on a single quality, while the effectiveness of space results from an entire group of qualities. Among the qualities surveyed in this study, green space and vegetation, a sense of security, privacy and coziness, climatic comfort, and safety of space were found to have the strongest positive effect on the reduction of stress, while noise pollution, vehicle traffic, and crowdedness were the most important factors of stress among the users of space.Examining the brain signals of the participants did not show any significant difference among the three street types, which may be explained by their anxiety about facing the EEG device, the small size of the sample, the nostalgic sense of the space for some participants, and the participant’s engagement with their mental preoccupations during the experiments. As with the sense of nostalgia, the two participants’ brain signals in Street B differed from the others and indicated a relatively more pleasant feeling. Interviews with these two participants revealed they had positive memories and experiences of this space. Good memories in space could probably counter the effect of negative components and reduce mental tension. In other words, it seems that the person’s perceived quality was different from that of the real space in a way that could reduce the deficiencies of the environment.Conversely, a person may not perceive the advantages of a desirable space for some reason. For example, four participants had weaker brain signals in Street A. When interviewed, two of them stated that a serious preoccupation had occurred to them just before taking part in the experiments, and they had been busy thinking about the issue during the walk. However, they had high scores for Type A in their questionnaire.Examining the level of EEG when the participants cross the intersections in Types A and B shows a decrease in relaxation. Another example is a flower store with a colorful showcase in Type C. In more than half of the subjects, the level of relaxation increased when watching the store. However, a more definite conclusion in this regard would require further research.Most studies on the relationship between environment and stress have only addressed one stressor, often virtually or in the lab. Among the few studies conducted in the real environment, this study addressed, for the first time, a set of factors that could affect stress. For this purpose, 16 students  aged 20-30 with normal health and stress levels were selected as participants. They wore an EEG device and walked on three street types. After each walk, they completed two questionnaires.The questionnaires’ findings suggest that green space and vegetation, a sense of security, privacy and coziness, climatic comfort, and safety of space were found to have the strongest positive effect on the reduction of stress, while noise pollution, vehicle traffic, and crowdedness were the most important factors of stress among the users of space. A comparison of the results concerning the street types indicates that although vehicle traffic, noise pollution, and the resulting sense of crowding increase stress levels, the quality of green space and vegetation in a street could mitigate these negative effects and even enhance positive components such as security in a way that the space might bear a generally positive effect on its users....green space and vegetation, a sense of security, privacy and coziness, climatic comfort, and safety of space were found to have the strongest positive effect on the reduction of stress, while noise pollution, vehicle traffic, and crowdedness were the most important factors of stress among the users of space.Appropriate vegetation to create pleasant colors and smells, using vegetation as acoustic insulation and safety walls for pedestrians, use of water in the design of pedestrian paths, focus on the climatic comfort of pedestrians, creating comfortable isolated spaces, and special design for intersections of pedestrian and vehicle paths are among the most important design features of shared streets that could help to produce less stressful spaces.Appropriate vegetation to create pleasant colors and smells, using vegetation as acoustic insulation and safety walls for pedestrians, use of water in the design of pedestrian paths, focus on the climatic comfort of pedestrians, creating comfortable isolated spaces, and special design for intersections of pedestrian and vehicle paths are among the most important design features of shared streets that could help to produce less stressful spaces.Decisive conclusions about the effects of pedestrian streets compared to motor vehicle streets with the dominance of green spaces require further research. Given the current tendency in urban centers toward constructing pedestrian streets which usually impose high costs on cities, it is necessary to focus on evaluating the effect of pedestrian streets on mental health compared with other street types. Our findings could motivate urban designers and planners to control environmental factors and conditions and improve the quality of public urban spaces to enhance people’s mental health.This was a pilot study with no financial support. The small sample size in this study limited the statistical power of our analysis and caused Type II errors (insignificance of the EEG results).Multichannel EEG is typically considered to be better than the single-channel EEG that we used because it provides more comprehensive information about brain activity. Our evaluations will be more precise and successful if we utilize more data from the five senses. In addition to a multi-channel EEG device, we suggest using a video camera and a voice recorder that record audiovisual data from the subjects during experiments. In this way, the voice, as well as the visual input of the subject, can be constantly monitored. In other words, we can partially perceive the space through the subjects’ point of view and examine the signals on crucial points to measure the effect of environmental factors on the brain.We should divide the environmental qualities (variables) affecting stress into two categories: acute and chronic stressors. Therefore, various methods must be considered. It is better to design long-term studies to measure the effects of variables, such as land use and physical activity. Based on the separation and link between acute stress/stressors and chronic stress/stressors, future studies can consider the effect of urban space on chronic stress by conducting longitudinal studies for a long time.We studied three types of streets in one city. After eliminating weaknesses and limitations, we considered replicating the study in a wider range of public urban spaces in different cities to make broader conclusions about the effects of urban environments on stress.Future research can investigate the effect of different urban spaces, the effect of spaces at different times of the day and night, and the effect of public urban spaces on various cultural groups. There is an important question: Do people from different cultural backgrounds perceive the quality of public urban spaces similarly?As the effects of urban stress on the nervous system are different in children and adults and people who grow up in large cities are at a greater risk of developing serious health problems in comparison with those who migrate to such cities in their adult life, design of child-friendly spaces entails that future studies address the effect of public urban spaces on children’s mental health.Green space is a crucial element of urban design that can effectively reduce stress levels. In land-use planning, the distribution and location of parks and green spaces should be carefully considered to ensure that they are easily accessible to all residents. Furthermore, in the process of subdividing and designing land, the width of streets should be defined with suitable and specific spaces for trees and vegetation cover, which can enhance the overall quality and accessibility of green spaces in urban areas.Urban planners and designers should consider designing an integrated network of green boulevards.A sense of security is a critical factor in reducing stress levels in urban spaces. To promote this sense of security, urban designers and planners should consider the use of Crime Prevention through Urban Design and Planning tools in the design of urban streets.Car-oriented streets cause more stress because of noise pollution, crowdedness, air pollution, and poor pedestrian safety. Urban designers should consider pedestrian-oriented street design and reduce the need for cars by designing an integrated urban transportation network.