Injury prevention in male veteran football players – a randomised controlled trial using “FIFA 11+”

The warm-up programme “FIFA 11+” has been shown to reduce football injuries in different populations, but so far veteran players have not been investigated. Due to differences in age, skill level and gender, a simple transfer of these results to veteran football is not recommended. The purpose of this study was to investigate the preventive effects of the “FIFA 11+” in veteran football players.

Twenty veteran football teams were recruited for a prospective 9-month (1 season) cluster-randomised trial. The intervention group (INT, n = 146; 45 ± 8 years) performed the “FIFA 11+” at the beginning of each training session, while the control group (CON, n = 119; 43 ± 6 years) followed its regular training routine. Player exposure hours and injuries were recorded according to an international consensus statement.

No significant difference was found between INT and CON in overall injury incidence (incidence rate ratio [IRR]: 0.91 [0.64–1.48]; P = 0.89). Only severe injuries reached statistical significance with higher incidence in CON (IRR: 0.46 [0.21–0.97], P = 0.04).

Regular conduction (i.e. once a week) of the “FIFA 11+” did not prevent injuries in veteran footballers under real training and competition circumstances. The lack of preventive effects is likely due to the too low overall frequency of training sessions.     

Effect of supramaximal exercise training on metabolic outcomes in obese adults

The purpose of this study was to evaluate the effects of 6 weeks of supramaximal exercise training (SET) on performance variables and metabolic changes in sedentary obese adults.

Twenty-four obese adults were randomly allocated into a non-trained (NT) [n = 12; body mass index (BMI) = 33(3)] and SET group [n = 12; BMI = (33(2)]. After baseline metabolic and fitness measurements, the participants completed a 6-week SET intervention. Metabolic, anthropometric, and fitness assessments were repeated post-intervention.

For SET, fasting glucose (4.64(0.15) vs. 4.32(0.22) mmol · l^–1; P < 0.01), insulin (23.2(4.6) vs. 13.8(3.3) µmol · ml^–1; P < 0.01), homoeostasis model assessment-insulin resistance index (4.78(1.2) vs. 2.65(1.5); P < 0.01) and systolic blood pressure (127(3) vs. 120(3) mmHg; P < 0.01) were significantly lower 24-h post-intervention than at baseline and for the NT group, and these changes remained significant at 72-h and 2-weeks post-intervention (P < 0.01, respectively). Interestingly, nonesterified fatty acids (0.62(0.09) vs. 0.71(0.11) mmol · l^–1; P < 0.01) and resting fat oxidation rate (57(11) vs. 63(4)%; P < 0.01) increased significantly from baseline 24-h post-intervention in the SET group and from baseline at 72-h (P < 0.01, respectively) and 2-weeks post-intervention (P < 0.01, respectively). Six weeks of SET improved a number of metabolic and vascular risk factors in obese, sedentary adults, highlighting the potential of SET to provide an alternative exercise model for the improvement of metabolic health in this population.     

Beneficial effect of enriched air nitrox on bubble formation during scuba diving. An open-water study

Bubble formation during scuba diving might induce decompression sickness.

This prospective randomised and double-blind study included 108 advanced recreational divers (38 females). Fifty-four pairs of divers, 1 breathing air and the other breathing nitrox28 undertook a standardised dive (24 ± 1 msw; 62 ± 5min) in the Red Sea. Venous gas bubbles were counted (Doppler) 30–<45 min (early) and 45–60 min (late) post-dive at jugular, subclavian and femoral sites.

Only 7% (air) vs. 11% (air28®) (n.s.) were bubble-free after a dive. Independent of sampling time and breathing gas, there were more bubbles in the jugular than in the femoral vein. More bubbles were counted in the air-group than in the air28-group (pooled vein: early: 1845 vs. 948; P = 0.047, late: 1817 vs. 953; P = 0.088). The number of bubbles was sex-dependent. Lastly, 29% of female air divers but only 14% of male divers were bubble-free (P = 0.058).

Air28® helps to reduce venous gas emboli in recreational divers. The bubble number depended on the breathing gas, sampling site and sex. Thus, both exact reporting the dive and in particular standardising sampling characteristics seem mandatory to compare results from different studies to further investigate the hitherto incoherent relation between inert gas bubbles and DCS.     

Acute adaptations and subsequent preservation of strength and speed measures following a Nordic hamstring curl intervention: a randomised controlled trial

This randomised controlled trial investigated changes in eccentric hamstring strength, 10m sprint speed, and change-of-direction (COD) performance immediately post Nordic hamstring curl (NHC) intervention and following a 3-week detraining period.

Fourteen male team sports athletes were randomised to a do-as-usual control group (CG; n = 7) or to a NHC intervention group (NHC; n = 7). Isokinetic dynamometry at 180°/s evaluated eccentric hamstring strength immediately post-intervention as the primary outcome measure. Secondary outcomes included 10 m sprint time and COD. Each outcome was measured, pre, immediately post-intervention and following a 3-week detraining period.

Immediately post-intervention significant group differences were observed in the NHC group for eccentric hamstring strength (31.81 Nm^?1 vs. 6.44 Nm^?1, P = 0.001), COD (?0.12 s vs. 0.20 s; P = 0.003) and sprint (- 0.06 s vs. 0.05 s; P = 0.024) performance. Performance improvements were maintained following a detraining period for COD (?0.11 s vs. 0.20 s; P = 0.014) and sprint (?0.05 s vs. 0.03 s, P = 0.031) but not eccentric hamstring strength (15.67 Nm^?1 vs. 6.44 Nm^?1, P = 0.145) These findings have important implications for training programmes designed to reduce hamstring injury incidence, whilst enhancing physical qualities critical to sport.     

Validity of an Athletic Skills Track among 6- to 12-year-old children

The purpose of this study was to examine the feasibility and validity of an Athletic Skills Track (AST) to assess fundamental movement skills among 6- to 12-year-old children in a physical education setting. Four hundred sixty-three Dutch children (211 girls, 252 boys) completed three tests: the Körperkoordinationstest für Kinder (KTK) and two Athletic Skills Tracks (AST-1, AST-2). The validity of AST-1 and AST-2 was examined by correlating the time (s) needed to complete the tracks and the KTK Motor Quotient (MQ).

Overall, there was a low correlation between AST-1 and the KTK MQ (r = –0.474 (P < 0.01)) and a moderate correlation between AST-2 and the KTK MQ (r = –0.502 (P < 0.01)). When split up by age group the associations were much higher and ranged between r = –0.469 and r = –0.767), with the exception of the low correlation coefficient of the AST-2 in 7-year-olds. The results indicate that fundamental movement skills of 6- to 12-year-old children can be assessed with a quick, convenient and low-cost motor competence test in a physical education setting, i.e., an Athletic Skills Track. Future studies should further assess the reliability, discriminative ability and validity of age-specific versions of the AST.     

Reliability of the virtual elevation method to evaluate rolling resistance of different mountain bike cross-country tyres

Although a low rolling resistance is advantageous in mountain bike cross-country racing, no studies have used the virtual elevation method to compare tyres from different manufacturers as used in international competitions so far. The aims of this study were to assess the reliability of this method, to compare the off-road rolling resistance between tyres and to calculate the influence on off-road speed.

Nine 29-in. mountain bike cross-country tyres were tested on a course representing typical ground surface conditions 5 or 6 times. The coefficient of rolling resistance was estimated with the virtual elevation method by 3 investigators and corresponding off-road speeds were calculated.

The virtual elevation method was highly reliable (typical error = 0.0006, 2.8%; limits of agreement <0.0005, r ≥ 0.98). The mean coefficient of rolling resistance was 0.0219 and differed from 0.0205 to 0.0237 (P < 0.001) between tyres. The calculated differences in off-road speed amounted to 2.9–3.2% (0% slope) and 2.3–2.4% (10% slope) between the slowest and the fastest tyre.

The reliability of the method and the differences in rolling resistance between the tyres illustrate the value of testing tyres for important competitions on a representative ground surface using the virtual elevation method.     

Criterion-related validity of self-report walking time from the EPIC questionnaire in older adults

Tools for measuring walking time make use of objective and subjective methods. One subjective approach is to administer physical activity questionnaires (PAQ), mainly because they are inexpensive and easy to give to large groups. The European Prospective Investigation into Cancer and Nutrition (EPIC) study has a brief PAQ (EPIC-PAQ) and includes one question referencing walking time. The objective of this study was to assess the validity of the question about time spent walking included in the EPIC-PAQ.

The sample included 200 older adults (113 women). To assess daily walking time, participants responded to the EPIC-PAQ in an interview and wore a portable gait analysis system and physical activity monitor for 48 consecutive hours in free-living condition.

Results indicated that the mean of bias between the EPIC-PAQ and objetive measurement was ?64.6 min/day. Also, the correlation was low compared to an objective measurement (rho = 0.196) and was positively correlated with the time spent at speeds below 2.5 mph but the correlation was low (slow walking rho = 0.154 and pace walking rho = 0.163).

The EPIC-PAQ shows low correlations with the objective measurement of walking time, that suggests it may be inaccurate and affecting the estimate of the EPIC-PAQ’s PA energy expenditure in this age group.     

Road cycle TT performance: Relationship to the power-duration model and association with FTP

Purpose: To determine the accuracy of critical power (CP) and W? (the curvature constant of the power-duration relationship) derived from self-paced time-trial (TT) prediction trials using mobile power meters to predict 16.1-km road cycling TT performance. This study also aimed to assess the agreement between functional threshold power (FTP) and CP.

Methods: Twelve competitive male cyclists completed an incremental test to exhaustion, a FTP test and 4–5 self-paced TT bouts on a stationary bike within the lab, and a 16.1 km road TT, using mobile power meters.

Results: CP and W? derived from the power-duration relationship closely predicted TT performance. The 16.1-km road TT completion time (26.7 ± 2.2 min) was not significantly different from and was significantly correlated with the predicted time-to-completion (27.5 ± 3.3 min, r = 0.89, P < 0.01). CP and FTP were not significantly different (275 ± 40 W vs. 278 ± 42 W, P > 0.05); however, the limits of agreement between CP and FTP were 30 to -36 W.

Discussion: The findings of this study indicate that CP and W? determined using mobile power meters during maximal, self-paced TT prediction trials can be used to accurately predict 16.1-km cycling performance, supporting the application of the CP and W? for performance prediction. However, the limits of agreement were too large to consider FTP and CP interchangeable.     

Emotional responses during repeated sprint intervals performed on level,downhill and uphill surfaces

The purpose of this study was to test emotional responses during sprint intervals performed on a level, down and up surface. Fifty trained participants performed a maximal effort during a 60-m sprint and 10 repetitions of 60 m running sprints on a level, down and up surface on a 5.9% slope. Running speeds, emotional responses and heart rate were measured. Self-selected speeds were correlated with the rating of perceived exertion, the affective balance, the desire to stop and the resources needed for the task in all conditions whereas the pleasure, the desire to continue and the capacity to realise the task were correlated with speeds only during level and uphill running. Mean values of emotional parameters were significantly different (P < 0.05) during running on a flat surface, downhill and uphill. When the gradient of running surface is changed, the pattern of emotional responses was just translated, i.e. most of the slope between the evolution of emotional parameters and the repetitions were not significantly different whereas Y-intercepts were different.

Consented effort is highly correlated with the resources needed for the task (P < 0.001, r² = 0.72). We propose that the difference in the resources needed for the task between level, downhill and uphill running (F _{2, 1499} = 166.5, P < 0.001, Eta² = 0.18) is the most important key that explains our results.     

The assessment of adolescent female athletes using standing and reactive long jumps

The aim of this study was to evaluate the reliability of two long jump tasks and their ability to predict 10 m sprint performance in elite adolescent female athletes. Eight junior national-level female track and field athletes completed three standing (SLJ) and reactive long jumps (RLJ) on portable force plates, followed by three 10 m sprints. Intra-class correlation coefficients (ICC) and coefficients of variation (CV) were calculated to examine reliability. Linear regression results identified the best predictor of average and best 10 m sprint time from the jump kinematic and kinetic measures. The ICCs and CVs indicated good reliability for the majority of kinetic measures however, better reliability was reported for the SLJ. The SLJ was a good predictor of best and average 10 m sprint time, with average horizontal power the best predictor of performance (best; R ² = 0.751, p = 0.003, Standard Error of Estimate (SEE)% = 2.2 average; R ² = 0.708, p = 0.005, SEE% = 2.5).     

Free-Living Comparison of Physical Activity and Sleep Data from Fitbit Activity Trackers Worn on the Dominant and Nondominant Wrists

Despite proprietary algorithms to account for differences, output from activity trackers worn on different wrists may not be comparable because individuals vary in their reliance on each hand during free-living activities.

Participants (n = 48) wore Fitbit Flex or Flex2 monitors on each wrist for three days. T tests, equivalence tests, and correlations were used to compare steps, Calories, distance, active minutes, and sleep duration recorded by dominant and nondominant wrist-worn monitors and effect sizes and mean absolute and percent difference were calculated.

The nondominant Flex2 monitor was not equivalent to the dominant wrist-worn monitor and recorded significantly more steps/day (absolute difference = 708), miles/day (0.3), and active minutes/day (7.9) than the dominant Flex2 monitor. For all variables, nondominant and dominant output was correlated (r>0.75).

Nondominant and dominant Flex2 monitors are significantly different, but there were small differences for Flex monitors. Research should investigate effects on behavior and replicate findings using other monitors.     

Longitudinal associations between motor competence and different physical activity intensities: LabMed physical activity study

An appropriated level of motor competence is essential for children´s healthy growth and development and a key factor in the promotion of lifelong active lifestyles and health.

The purpose of this study was to examine associations between motor competence and different physical activity intensities (light, moderate, moderate-to-vigorous and vigorous physical activity), as well as total physical activity, over a two-year period, in adolescents. The sample comprised of 103 adolescents (13.49 ± 0.87 years, 53 girls), from the north of Portugal. Motor competence was evaluated with the body coordination test, Körperkoordination-Test-für-Kinder. Physical activity was objectively assessed with GT1M accelerometers (ActiGraph, Pensacola, FL, USA). Physical activity variables were expressed as proportions of accelerometer wear time. Regression analyses showed positive longitudinal associations between motor competence at baseline and moderate physical activity (B = 0.0033, p = 0.018), moderate-to-vigorous physical activity (B = 0.0052, p = 0.024) and total physical activity (B = 0.067, p = 0.040) at follow up, after adjustments for age, sex, the corresponding physical activity intensity at baseline, body mass index, pubertal stage and socioeconomic status. Our ?ndings highlight the importance of motor competence development to promote moderate-to-vigorous physical activity during adolescence.     

Relative age effect: Characteristics of youth soccer players by birth quarter and subsequent playing status

Purpose: To compare characteristics of club level male soccer players 11 and 13 years of age, and to evaluate playing status in soccer two and 10 years after baseline by birth quarter (BQ).

Methods: Youth players 11 (n = 62, born 1992, observed December 2003) and 13 (n = 50, born 1990, observed April 2004) years were grouped by BQ. Baseline data included stature, weight, maturity status, functional capacities, soccer skills, goal orientation, and coach evaluation of potential. Playing status in soccer in 2006 and 2014 was also available. Baseline characteristics and subsequent playing status were compared by BQ.

Results: Baseline characteristics did not differ by BQ except for age and percentage of predicted adult height. Though not significant, coaches tended to rate players in BQ1as higher in potential. For those competing in soccer as adults, BQ2 (4), BQ3 (5) and BQ4 (2) were represented among players11 years, and BQ1 (3), BQ2 (2), BQ3 (1) and BQ4 (4) among players 13 years.

Conclusion: Although limited to small numbers, differences among players by BQ were inconsistent. The results indicate a need to extend potential explanations of the RAE to include behavioral variables, coaches, training environment, and perhaps the culture of the sport.     

The productive effect of power: (dis)pleasurable bodies materialising in and through the discursive practices of boys’ physical education

Background: Pleasure is often a key feature of school physical education (PE) and, indeed, a lot of students find pleasure in and through PE while others do not. However, pleasure is rarely considered to be of educational value in the subject [Pringle, R. (2010). “Finding Pleasure in Physical Education: A Critical Examination of the Educative Value of Positive Movement Affects.” Quest 62: 119–134]. Further, since pleasure is linked to power [Foucault, M. (1980). Power/Knowledge: Selected Interviews and Other Writings, 1972–1977. New York: Pantheon; Gerdin, G., and R. Pringle. (2015). “The Politics of Pleasure: An Ethnographic Examination Exploring the Dominance of the Multi-Activity Sport-Based Physical Education Model.” Sport, Education and Society. doi:10.1080/13573322.2015.1019448] it is in fact not entirely straightforward to legitimise the educational value of PE in relation to pleasure.

Purpose: In this paper, we explore how a group of boys derive pleasures from their involvement in PE, but also how these power-induced pleasures are integral to gender normalisation processes. The findings presented are particularly discussed in terms of inclusive/exclusive pedagogical practices related to gender, bodies and pleasures.

Research setting and participants: The research setting was a single-sex, boys’ secondary school in Auckland, New Zealand. Participants in this study were 60 Year 10 (age 14–15) students from two PE classes.

Data collection and analysis: Using a visual ethnographic approach [Pink, S. (2007). Doing Visual Ethnography. London: Sage] involving observations and video recordings of boys participating in PE, the boys’ representations and interpretations of the visual data were explored during both focus groups and individual interviews. The data were analysed using (a visually oriented) discourse analysis [Foucault, M. (1998). “Foucault.” In Michel Foucault. Aesthetics, Method and Epistemology, edited by J. D. Faubion, 459–463. New York: The New Press; Rose, G. (2007). Visual Methodologies: An Introduction to the Interpretation of Visual Materials. London: Sage].

Findings: By elucidating the discursive practices of PE in this setting and employing (Butler, J. (1993). Bodies that Matter: On the Discursive Limits of ‘Sex’. New York: Routledge] concept of ‘materialisation’, we suggest that boy’s bodies materialise as productive and pleasurable or displeasurable bodies through submitting/subjecting to certain bodily regimes, developing embodied mastery when it comes to certain sports, and displaying bodies in particular ways. The analysis indicate that the discursive practices of PE contribute to boys’ bodies materialising as pleasurable or displeasurable and the (re)production of gender in the subject as shaped by discourse and the productive effect of power.

Discussion and conclusions: In line with [Gard, M. (2008). “When a Boy’s Gotta Dance: New Masculinities, Old Pleasures.” Sport, Education and Society 13 (2): 181–193], we conclude that the focus on certain discursively constructed bodily practices at the same time continues to restrict the production of a diversity of bodily movement pleasures. Hence, traditional gender patterns are reproduced through a selection of particular sports/physical activities that all the students are expected to participate in. We propose that the ongoing constitution of privileged forms of masculinity, masculine bodies and masculine pleasures as related to fitness, health and sport and (certain) boys’ subsequent exercise of power in PE needs further critical examination.     

‘You have to find your slant,your groove:’ one physical education teacher's efforts to employ transformative pedagogy

Background: Teaching for social good and inequity has been presented as needed in sport pedagogy research. However, very little is known how transformative pedagogical practices that teach for social good are implemented and sustained at the elementary level.

Purpose: This digital ethnographic study sought to describe one elementary school physical education (PE) teacher's attempt to employ transformative pedagogy (TP).

Method: Cochran-Smith's [1998. “Teaching for Social Change: Toward a Grounded Theory of Teacher Education.” In The International Handbook of Educational Change, edited by A. Hargreaves, A. Lieberman, M. Fullan, and D. Hopkins, 916–952. Netherlands: Kluwer Academic Publishers, 2004. Walking the Road: Race, Diversity, and Social Justice in Teacher Education. New York: Teachers College Press] pedagogical principles for social justice education (SJE) drove our data collection and analysis. Seven qualitative methods were employed to collect data about Harry's pedagogies, organizational structures, and the content he taught. These were formal and informal interviews, conversations, short films, document collection, social media accounts, and an electronic journal. Data were analyzed using both inductive and deductive methods [Patton 2015. Qualitative Research and Evaluation Methods. 4th ed. Thousand Oaks: Sage].

Findings: Harry's TP and the factors that facilitated and limited his practice were uncovered within five main themes: (a) creating communities of learners through restorative practice principles, (b) building on what students bring to school with them for a democratic curriculum, (c) teaching skills, bridging gaps, and the affective component, (d), working with communities in-between social justice illiteracy, and (e) utilizing diverse forms of assessment.

Conclusion: We confirmed that there is no best way to teach social justice through PE and that TP must be individual to the teacher. In addition, this study highlighted methods and pedagogies by which teachers could engage in TP. Finally, the study's findings implied how teacher educators might go about working with both preservice and inservice PE teachers with the goal that they focus on facilitating social justice through their pedagogical approach.     

Kinematics of judo breakfall for osoto-gari: Considerations for head injury prevention

Previous studies suggest that increasing the skill level of judokas will decrease the number of head injuries sustained during judo. However, the kinematics are poorly understood, making it difficult to establish an effective breakfall teaching programme. Therefore, we studied the kinematic parameters of breakfall for osoto-gari to identify the risk of judo-related head injuries by comparing experienced and novice judokas. This information will provide insight into developing a better prevention plan for judo-related head injuries.

A total of 10 experienced and 12 novice judokas volunteered to participate in this study. The kinematic data of the breakfall motion for osoto-gari were collected using a three-dimensional motion analysis technique (200 Hz).

We observed a significantly higher peak neck extension momentum in the novice group than in the experienced group. This suggests that neck extension momentum during breakfall is associated with the risk of head injuries during judo. In addition, the novice judokas demonstrated a significantly greater flexed pattern in the trunk and hip movement than the experienced judokas (P < 0.05). The results suggest that the trunk and lower extremity motion are important kinematic parameters that determine the skill level in performing the breakfall for osoto-gari.     

Effects of a nonlinear pedagogy intervention programme on the emergent tactical behaviours of youth footballers

Purpose: This study analysed the effects of a training intervention programme using principles of Non-Linear Pedagogy (NLP) on the decision making (DM) and performance behaviours (P) of youth footballers.

Method: 19 footballers (U12 yrs) participated in 14 training sessions, spread over three phases: Pre-intervention, Intervention, Retention. The intervention was based on Small-Sided and Conditioned Games. We assessed progress during the intervention phase at two different points: intermediate and final. The GPET instrument was used to analyse the DM and P during the completion of 3208 passes in the intervention.

Results: Results shown significant improvements in the DM and P after the intermediate and final points of the acquisition phase. Moreover, significantly higher values were also obtained in both variables in the retention, compared to the pre-intervention phase.

Conclusion: Results indicated that the NLP intervention programme was effective in improving both aspects of team games performance in youth players, with effects consolidated over time.     

Human runners exhibit a least variable gait speed

This study characterises the relationship between gait variability and speed in runners using data from trunk accelerations in each axis.

Twelve participants of varying fitness ran on the treadmill with three sessions of six randomly ordered self-selected speeds. A VO_2max test was conducted on the fourth session. Running gait was tracked with inertial sensors. The occurrence of a mid-range speed was analysed for the anterior–posterior, vertical and lateral directional coefficient of variation (CV) of root mean square (RMS) acceleration data.

One participant with noisy gait signals was omitted. The results show all remaining participants consistently showed significant quadratic U-shaped relationships between vertical RMS CV acceleration and speed. Neither anterior–posterior nor lateral RMS CV acceleration were clearly related to speed. These least variable gait speeds were similar to estimates of optimal speed derived from minimum cost of transport with speed.

In conclusion, there exists a mid-range speed for each runner with the least variable gait in the vertical direction, and this occurred significantly more often than would be expected by chance (P < 0.05). However, there are no prominent patterns for the anterior–posterior and lateral directions. This finding supports anecdotal evidence from runners and coaches concerning gait consistency.     

Test-retest reliability and agreement of the SPI-Questionnaire to detect symptoms of digital ischemia in elite volleyball players

The Shoulder posterior circumflex humeral artery Pathology and digital Ischemia – questionnaire (SPI-Q) has been developed to enable periodic surveillance of elite volleyball players, who are at risk for digital ischemia. Prior to implementation, assessing reliability is mandatory. Therefore, the test-retest reliability and agreement of the SPI-Q were evaluated among the population at risk.

A questionnaire survey was performed with a 2-week interval among 65 elite male volleyball players assessing symptoms of cold, pale and blue digits in the dominant hand during or after practice or competition using a 4-point Likert scale (never, sometimes, often and always). Kappa (κ) and percentage of agreement (POA) were calculated for individual symptoms, and to distinguish symptomatic and asymptomatic players. For the individual symptoms, κ ranged from “poor” (0.25) to “good” (0.63), and POA ranged from “moderate” (78%) to “good” (97%). To classify symptomatic players, the SPI-Q showed “good” reliability (κ = 0.83; 95%CI 0.69–0.97) and “good” agreement (POA = 92%). The current study has proven the SPI-Q to be reliable for detecting elite male indoor volleyball players with symptoms of digital ischemia.