The The role of heart rate variability in the prevention of musculoskeletal injuries in female padel players

  • Francesca Latino Pegaso University, 80143 Napoli NA, Italy
  • Pierpaolo Limone Pegaso University, 80143 Napoli NA, Italy
  • Francesco Peluso Cassese Pegaso University, 80143 Napoli NA, Italy
  • Rosabel Martinez-Roig University of Alicante, 03001 Alicante, Spain
  • Alessandro Persico University of Naples “Parthenope”, 80133 Napoli NA, Italy
  • Francesco Tafuri Unicusano University, 00166 Roma RM, Italy
Keywords: autonomic nervous system; overuse injuries; exercise; athletic performance; anatomy; physiology
Article ID: 1350

Abstract

The engagement of athletes in competitive Padel is becoming progressively prevalent, and this heightened participation elicits apprehensions regarding the prevalence of overtraining and sports-related injuries. In this framework, the objective of the present investigation was to examine the potential role of Heart Rate Variability (HRV) monitoring in identifying overtraining injuries among female professional Padel athletes. A cohort of 66 elite female Padel players, with ages ranging from 17 to 32 years, was recruited for the study. The duration of the investigation extended over a 13-week period, during which the participants were observed concerning HRV indices and musculoskeletal injuries while adhering to their customary Padel training protocols. The assessment of HRV indices was executed to ascertain the autonomic nervous system’s response to a state of overload injury, while the Oslo Sports Trauma Research Center (OSTRC) Overuse Injury Questionnaire was administered to assess the prevalence of musculoskeletal overuse injuries, both at baseline and upon completion of the observational period. Utilizing a Paired Samples t-test analysis, the results indicated a statistically significant difference between pre- and post-test assessments, which illustrated that the observational cohort experienced a notable decline in HRV concomitant with an escalation in the incidence of musculoskeletal overuse injuries. Consequently, the findings imply that the monitoring of HRV responses may facilitate the early detection of overuse injuries, inform rehabilitation strategies, and advance return-to-sport protocols, thereby safeguarding and promoting the recovery of injured tissues.

References

1. Sánchez-Alcaraz BJ, Courel-Ibáñez J. The role of Padel in improving physical fitness and health promotion: progress, limitations, and future perspectives—A narrative review. International Journal of Environmental Research and Public Health. 2022; 19(11): 6582.

2. Priego JI, Melis JO, Belloch SL, et al. Padel: A Quantitative study of the shots and movements in the high-performance. Journal of Human Sport and Exercise. 2013; 8(4): 925–931.

3. Giustino V, Figlioli F, Patti A, et al. Injuries in Padel players: What is known? A scoping review. International Journal of Sports Science & Coaching. 2024; 19(3): 1286–1295.

4. Patel DR, Yamasaki A, Brown K. Epidemiology of sports-related musculoskeletal injuries in young athletes in United States. Translational pediatrics. 2017; 6(3): 160.

5. Goes RA, Lopes LR, Cossich VRA, et al. Musculoskeletal injuries in athletes from five modalities: A cross-sectional study. BMC Musculoskeletal Disorders. 2020; 21(1): 122.

6. Valério MM, Drews R, Macksoud MP, Silva FMD. Injuries in competitive sports: an analysis of Brazilian padel athletes. Fisioterapia e Pesquisa. 2022; 29(1): 74–80.

7. de Sire A. Sports-related musculoskeletal injuries: From diagnostics to rehabilitation. Journal of Back and Musculoskeletal Rehabilitation. 2022; 35(4): 687–689.

8. Armstrong LE, Bergeron MF, Lee EC, et al. Overtraining syndrome as a complex systems phenomenon. Frontiers in network physiology. 2022; 1: 794392.

9. Dahmen J, Emanuel KS, Fontanellas-Fes A, et al. Incidence, prevalence and nature of injuries in padel: a systematic review. BMJ Open Sport & Exercise Medicine. 2023; 9(2): e001607.

10. Demeco A, de Sire A, Marotta N, et al. Match analysis, physical training, risk of injury and rehabilitation in padel: Overview of the literature. International Journal of Environmental Research and Public Health. 2022; 19(7): 4153.

11. Priego JI, Kerr ZY, Sanchís Almenara M, Alcantara E. Examination of the risk factors associated with injured recreational padel players in Spain. The Journal of sports medicine and physical fitness. 2016; 58(1–2): 98–105.

12. Muñoz D, Coronado M, Robles-Gil MC, et al. Incidence of upper body injuries in amateur padel players. International journal of environmental research and public health. 2022; 19(24): 16858.

13. Brenner JS, Watson A, Brooks MA, et al. Overuse injuries, overtraining, and burnout in young athletes. Pediatrics. 2024; 153(2): e2023065129.

14. Gisselman AS, Baxter GD, Wright A, et al. Musculoskeletal overuse injuries and heart rate variability: Is there a link? Medical Hypotheses. 2016; 87: 1–7.

15. Gisselman AS. Exploring the Association between Musculoskeletal Overuse Injuries and Heart Rate Variability [PhD thesis]. University of Otago; 2018.

16. Guthrie C, Williams, S. Musculoskeletal overuse injuries in runners and heart rate variability: Is there a link? Physiotherapy. 2021; 113: e93–e94.

17. Timpka T. Mediating factors of pain associated with overuse injury in elite Athletics athletes. Journal of Science and Medicine in Sport. 2017; 20: e19–e20.

18. Lundstrom CJ, Foreman NA, Biltz G. Practices and applications of heart rate variability monitoring in endurance athletes. International Journal of Sports Medicine. 2023; 44(1): 9–19.

19. Boullosa D, Medeiros AR, Flatt AA, et al. Relationships between workload, heart rate variability, and performance in a recreational endurance runner. Journal of Functional Morphology and Kinesiology. 2021; 6(1): 30.

20. Zhou K. Design of Training Load Monitoring and Adjustment Algorithm for Athletes: Based on Heart Rate Variability and Body Index Data. Journal of Electrical Systems. 2024; 20(6s): 1600–1611.

21. Tiwari R, Kumar R, Malik S, et al. Analysis of heart rate variability and implication of different factors on heart rate variability. Current cardiology reviews. 2021; 17(5): e16072118977.

22. Addleman JS, Lackey NS, DeBlauw JA, Hajduczok AG. Heart Rate Variability Applications in Strength and Conditioning: A Narrative Review. Journal of Functional Morphology and Kinesiology. 2024; 9(2): 93.

23. Speer KE, Naumovski N, McKune AJ. Heart rate variability to track autonomic nervous system health in young children: Effects of physical activity and cardiometabolic risk factors. Physiology & Behavior. 2024; 281: 114576.

24. Stepanyan L, Lalayan G. Heart rate variability features and their impact on athletes’ sports performance. Journal Of Physical Education and Sport. 2023; 23(8): 2156–2163.

25. Matsumura S, Watanabe K, Saijo N, et al. Positive relationship between precompetitive sympathetic predominance and competitive performance in elite extreme sports athletes. Frontiers in Sports and Active Living. 2021; 3: 712439.

26. Mishica C, Kyröläinen H, Hynynen E, et al. Relationships between heart rate variability, sleep duration, cortisol and physical training in young athletes. Journal of Sports Science & Medicine. 2021; 20(4): 778.

27. Horvath E, Kovacs MT, Toth D, Toth L. A study of the relationship between anxiety, cognitive emotion regulation and heart rate variability in athletes. Journal of Physical Education and Sport. 2022; 22(2): 528–534.

28. Pagaduan JC, Chen YS, Fell JW, Xuan Wu SS. A preliminary systematic review and meta-analysis on the effects of heart rate variability biofeedback on heart rate variability and respiration of athletes. Journal of Complementary and Integrative Medicine. 2022; 19(4): 817–826.

29. Manresa-Rocamora A, Sarabia JM, Javaloyes A, et al. Heart rate variability-guided training for enhancing cardiac-vagal modulation, aerobic fitness, and endurance performance: A methodological systematic review with meta-analysis. International Journal of Environmental Research and Public Health. 2021; 18(19): 10299.

30. Stephenson MD, Thompson AG, Merrigan JJ, et al. Applying heart rate variability to monitor health and performance in tactical personnel: A narrative review. International Journal of Environmental Research and Public Health. 2021; 18(15): 8143.

31. Gronwald T, Rogers B, Hottenrott L, et al. Correlation properties of heart rate variability during a marathon race in recreational runners: Potential biomarker of complex regulation during endurance exercise. Journal of Sports Science & Medicine. 2021; 20(4): 557.

32. Boullosa D, Medeiros AR, Flatt AA, et al. Relationships between workload, heart rate variability, and performance in a recreational endurance runner. Journal of Functional Morphology and Kinesiology. 2021; 6(1): 30.

33. Almomani M, Almomani M. Comprehensive study on musculoskeletal injuries among swimmers in Jordan: Causes, effects, and prevention strategies. Eur. J. Med. Health Sci. 2024; 6(1): 20–29.

34. Grimm DR, Cunningham BM, Burke JR. Autonomic nervous system function among individuals with acute musculoskeletal injury. Journal of Manipulative and Physioloical Therapeutics. 2005; 28(1): 44–51.

35. Arslan D, Ünal Çevik I. Interactions between the painful disorders and the autonomic nervous system. Agri-the Journal of the Turkish Society of Algology. 2022; 34(3): 155–165.

36. Passatore M, Roatta S. Influence of sympathetic nervous system on sensorimotor function: Whiplash associated disorders (WAD) as a model. European Journal of Applied Physiology. 2006; 98(5): 423–449.

37. Rome PL. Neurovertebral influence upon the autonomic nervous system: Some of the somato-autonomic evidence to date. Chiropractic Journal of Australia. 2009; 39(1): 2–17.

38. Latino F, Tafuri F. Wearable Sensors and the Evaluation of Physiological Performance in Elite Field Hockey Players. Sports. 2024; 12(5): 124.

39. Parraca JA, Alegrete J, Villafaina S, et al. Heart rate variability monitoring during a padel match. International Journal of Environmental Research and Public Health. 2022; 19(6): 3623.

40. Tiwari R, Kumar R, Malik S, et al. Analysis of heart rate variability and implication of different factors on heart rate variability. Current cardiology reviews. 2021; 17(5): e160721189770.

41. Yoo JH, Son HM, Jeong H, et al. Personalized federated learning with clustering: Non-IID heart rate variability data application. In: Proceedings of the12th International Conference on Information and Communication Technology Convergence (ICTC); 20–22 October 2021; Jeju Island, Korea.

42. Al-Sakini N. Anatomy of the heart. Medicine. 2022; 50(6): 317–321.

43. Schaffarczyk M, Rogers B, Reer R, Gronwald T. Validity of the polar H10 sensor for heart rate variability analysis during resting state and incremental exercise in recreational men and women. Sensors. 2022; 22(17): 6536.

44. Gilgen-Ammann R, Roos L, Wyss T, et al. Validation of ambulatory monitoring devices to measure energy expenditure and heart rate in a military setting. Physiological Measurement. 2021; 42(8): 085008.

45. Clarsen B, Myklebust G, Bahr R. Development and validation of a new method for the registration of overuse injuries in sports injury epidemiology: The Oslo Sports Trauma Research Centre (OSTRC) overuse injury questionnaire. British journal of sports medicine. 2013; 47(8): 495–502.

46. Augustsson SR, Lundin F. Injuries and risk factors in Swedish padel. Sports Orthopaedics and Traumatology. 2023; 39(1): 68–76.

47. Alito A, Leonardi G, Portaro S, et al. The Padel phenomenon after the COVID-19: An Italian cross-sectional survey of post-lockdown injuries. European Journal of Translational Myology. 2024; 34(2): 12331.

48. Sánchez-Alcaraz BJ, Martínez-Gallego R, Llana S, et al. Ball impact position in recreational male padel players: Implications for training and injury management. International Journal of Environmental Research and Public Health. 2021; 18(2): 435.

49. Hak PT, Hodzovic E, Hickey B. The nature and prevalence of injury during CrossFit training. Journal of Strength and Conditioning Research. 2013.

50. Vermeule E. Systems thinking as a novel framework to study overuse injuries in endurance running [PhD thesis]. Stellenbosch University; 2021.

51. Meneghetti HG, Souza GCD, Santos JGF, et al. The use of heart rate variability analysis in monitoring sport injuries and its influence on the autonomic balance: A systematic review. Fisioterapia e Pesquisa. 2021; 28: 291–298.

52. Barreto AC, Medeiros AP, da Silva Araujo G, et al. Heart rate variability and blood pressure during and after three CrossFit® sessions. Retos. 2013; 47: 311–316.

53. Tamminen KA, Bonk D, Milne MJ, Watson JC. Emotion dysregulation, performance concerns, and mental health among Canadian athletes. Scientific Reports. 2025; 15(1): 2962.

54. Parks A, Hogg-Johnson S. Autonomic nervous system dysfunction in pediatric sport-related concussion: A systematic review. The Journal of the Canadian Chiropractic Association. 2023; 67(3): 246.

55. Ribeiro N, Martinho DV, Pereira JR, et al. Injury Risk in Elite Young Male Soccer Players: A Review on the Impact of Growth, Maturation, and Workload. The Journal of Strength & Conditioning Research. 2024; 38(10): 1834–1848.

56. Torres R. Biofeedback using virtual reality, conscious interoception, and breathing exercises modulates blood pressure and heart rate variability in people with and without cervical spinal cord injuries [PhD thesis]. University of Louisville; 2024.

57. Herrington L, Ranson C, McCaig S, et al. 9.10 Is there an elevated risk of subsequent musculoskeletal injury following a sports related concussion across UK Olympic sports? British Journal of Sports Medicine. 2023; 58(1).

58. Sonkodi B, Radovits T, Csulak E, et al. Orthostasis Is Impaired Due to Fatiguing Intensive Acute Concentric Exercise Succeeded by Isometric Weight-Loaded Wall-Sit in Delayed-Onset Muscle Soreness: A Pilot Study. Sports. 2023; 11(11): 209.

59. Nayak SK, Pradhan B, Mohanty B, et al. A Review of Methods and Applications for a Heart Rate Variability Analysis. Algorithms. 2023; 16(9): 433.

60. Maqsood R, Khattab A, Bennett AN, Boos CJ. Association between non-acute Traumatic Injury (TI) and Heart Rate Variability (HRV) in adults: A systematic review and meta-analysis. PLoS One. 2023; 18(1): e0280718.

61. Maqsood R, Khattab A, Bennett AN, Boos CJ. Association between non-acute traumatic injury (TI) and heart rate variability (HRV) in adults: A systematic review protocol. PloS One. 2022; 17(8): e0273688.

62. Casanova-Lizon A, Manresa-Rocamora A, Flatt AA, et al. Does exercise training improve cardiac-parasympathetic nervous system activity in sedentary people? A systematic review with meta-analysis. International Journal of Environmental Research and Public Health. 2022; 19(21): 13899.

63. Claiborne A, Alessio H, Slattery E, et al. Heart rate variability reflects similar cardiac autonomic function in explosive and aerobically trained athletes. International Journal of Environmental Research and Public Health. 2021; 18(20): 10669.

64. La Fountaine MF, Toda M, Testa A, Hill-Lombardi V. Autonomic nervous system responses to concussion: Arterial pulse contour analysis. Frontiers in neurology. 2016; 7: 13.

65. Royes LFF, Santos ARS, Marques JLB. Alteration in Autonomic Function Induced by Moderate Fluid Percussion Injury Model in Rats. In: Proceedings of the 6th Brazilian Technology Symposium (BTSym’20): Emerging Trends and Challenges in Technology. Springer Publishing; 2021. p. 200.

66. Talbert LD, Kaelberer Z, Gleave E, et al. A Systematic Review of the Relationship Between Traumatic Brain Injury and Disruptions in Heart Rate Variability. Applied Psychophysiology and Biofeedback. 2024; 49(4): 523–540.

67. Harrison A, Lane-Cordova A, La Fountaine MF, Moore RD. Concussion history and heart rate variability during bouts of acute stress. Journal of Athletic Training. 2022; 57(8): 741–747.

68. Grimm DR, Cunningham BM, Burke R. Autonomic nervous system function among individuals with acute musculoskeletal injury. Journal of Manipulative and Physiological Therapeutics. 2005; 28(1): 44–51.

69. Pontes-Silva, A., Bassi-Dibai, D., Fidelis-de-Paula-Gomes, C. A., Souza, C. D. S., Pires, F. D. O., Mostarda, C. T., & Dibai Filho, A. V. (2022). Comparison of the autonomic nervous system dysfunction between different chronic spine disorders: neck pain versus low back pain. Revista da Associação Médica Brasileira, 68(9), 1288-1296.

70. Hartzell MM, Dodd CD, Gatchel RJ. Stress and musculoskeletal injury. In: Cooper C, Quick JC (editors). The handbook of stress and health: A guide to research and practice. Wiley-Blackwell Publishing; 2017. pp. 210–222.

71. Diaz-Saez MC, La Touche R, Cuenca-Martinez F. Comparative analysis of the autonomic nervous system response during movement representation in healthy individuals and patients with chronic low back pain: A prospective cohort study. Somatosensory & Motor Research. 2021; 38(1): 68–76.

72. Daniela M, Catalina L, Ilie O, et al. Effects of exercise training on the autonomic nervous system with a focus on anti-inflammatory and antioxidants effects. Antioxidants. 2022; 11(2): 350.

73. Kox M, Ramakers BP, Pompe JC, van der Hoeven JG, et al. Interplay between the acute inflammatory response and heart rate variability in healthy human volunteers. Shock. 2011; 36(2): 115–120.

74. Mertens MG, Struyf F, Girbes EL, et al. Autonomic nervous system function and central pain processing in people with frozen shoulder: A case-control study. The Clinical Journal of Pain. 2022; 38(11): 659–669.

75. Karrow NA. Activation of the hypothalamic–pituitary–adrenal axis and autonomic nervous system during inflammation and altered programming of the neuroendocrine–immune axis during fetal and neonatal development: Lessons learned from the model inflammagen, lipopolysaccharide. Brain, behavior, and immunity. 2006; 20(2): 144–158.

76. Jiang Y, Yabluchanskiy A, Deng J, et al. The role of age-associated autonomic dysfunction in inflammation and endothelial dysfunction. Geroscience. 2022; 44(6): 2655–2670.

77. Oura P, Hautala A, Kiviniemi A, et al. Musculoskeletal pains and cardiovascular autonomic function in the general Northern Finnish population. BMC musculoskeletal disorders. 2019; 20: 1–12.

78. Pertab JL, Merkley TL, Cramond AJ, et al. Concussion and the autonomic nervous system: An introduction to the field and the results of a systematic review. NeuroRehabilitation. 2018; 42(4): 397–427.

79. Williams DP, Koenig J, Carnevali L, et al. Heart rate variability and inflammation: a meta-analysis of human studies. Brain, behavior, and immunity. 2019; 80: 219–226.

80. Aeschbacher S, Schoen T, Dörig L, et al. Heart rate, heart rate variability and inflammatory biomarkers among young and healthy adults. Annals of medicine. 2017; 49(1): 32–41.

81. Thomas BL, Claassen N, Becker P, Viljoen M. Validity of commonly used heart rate variability markers of autonomic nervous system function. Neuropsychobiology. 2019; 78(1): 14–26.

82. Gullett N, Zajkowska Z, Walsh A, et al. Heart rate variability (HRV) as a way to understand associations between the autonomic nervous system (ANS) and affective states: A critical review of the literature. International Journal of Psychophysiology. 2023; 35–42.

83. Jewson JL, Lambert GW, Storr M, Gaida JE. The sympathetic nervous system and tendinopathy: A systematic review. Sports Medicine. 2015; 45(5): 727–743.

84. Lima-Borges DS, Martinez PF, Vanderlei LCM, et al. Autonomic modulations of heart rate variability are associated with sports injury incidence in sprint swimmers. The Physician and Sportsmedicine. 2018; 46(3): 374–384.

85. Williams S, Booton T, Watson M, et al. Heart rate variability is a moderating factor in the workload-injury relationship of competitive CrossFitTM athletes. Journal of Sports Science & Medicine. 2017; 16(4): 443.

86. Flores G, Monteiro D, Silva F, Duarte-Mendes P. Heart rate variability activity in soccer athletes after a musculoskeletal injury. Journal of Rehabilitation Medicine. 2024; 56.

87. Cocco G, Ricci V, Corvino A, et al. Musculoskeletal disorders in padel: From biomechanics to sonography. Journal of Ultrasound. 2024; 27(2): 335–354.

88. Augustsson SR, Lundin F. Injuries and risk factors in Swedish padel. Sports Orthopaedics and Traumatology. 2023; 39(1): 68–76.

89. García-Fernández P, Guodemar-Pérez J, Ruiz-López M, et al. Epidemiology of injuries in professional and amateur Spanish paddle players. International Journal of Medicine & Science of Physical Activity & Sport/Revista Internacional de Medicina y Ciencias de la Actividad Física y del Deporte. 2019; 19(76).

90. Courel-Ibanez J, Martinez BJSA, Marín DM. Exploring game dynamics in padel: Implications for assessment and training. The Journal of Strength & Conditioning Research. 2019; 33(7): 1971–1977.

91. Alito A, Leonardi G, Portaro S, et al. The Padel phenomenon after the COVID-19: An Italian cross-sectional survey of post-lockdown injuries. European Journal of Translational Myology. 2024; 34(2): 12331.

92. de Sire A. Sports-related musculoskeletal injuries: From diagnostics to rehabilitation. Journal of Back and Musculoskeletal Rehabilitation. 2022; 35(4): 687-689.

93. Castillo-Lozano R, Casuso-Holgado MJ. A comparison musculoskeletal injuries among junior and senior paddle-tennis players. Science & Sports. 2015; 30(5): 268–274.

94. Castillo-Lozano R. Epidemiology and prevention strategies for the musculoskeletal injuries in the paddle-tennis senior players. Revista Andaluza de Medicina del Deporte. 2015; 8(4): 188–188.

95. Aicale R, Tarantino D, Maffulli N. Overuse injuries in sport: A comprehensive overview. Journal of orthopaedic surgery and research. 2018; 13(1): 309.

96. Martin S, Johnson U, McCall A, Ivarsson A. Psychological risk profile for overuse injuries in sport: An exploratory study. Journal of Sports Sciences. 2021; 39(17): 1926–1935.

97. Franco MF, Madaleno FO, de Paula TM, et al. Prevalence of overuse injuries in athletes from individual and team sports: A systematic review with meta-analysis and GRADE recommendations. Brazilian Journal of Physical Therapy. 2021; 25(5): 500–513.

98. Brenner JS, Watson A, Brooks MA, et al. Overuse injuries, overtraining, and burnout in young athletes. Pediatrics. 2024; 153(2).

99. Kalkhoven JT, Watsford ML, Impellizzeri FM. A conceptual model and detailed framework for stress-related, strain-related, and overuse athletic injury. Journal of Science and Medicine in Sport. 2020; 23(8): 726–734.

100. Tranaeus U, Martin S, Ivarsson A. Psychosocial risk factors for overuse injuries in competitive athletes: A mixed-studies systematic review. Sports Medicine. 2022; 52(4): 773–788.

101. Xie J, Fu M, Liu T, et al. Clinical studies on the electric automatic massage therapy for recovery of acute sports fatigue. Technology and Health Care. 2023; 31(S1): 185–197.

102. Bittencourt NFN, Meeuwisse WH, Mendonça LD, et al. Complex systems approach for sports injuries: Moving from risk factor identification to injury pattern recognition-narrative review and new concept. British Journal of Sports Medicine. 2016; 50(21): 1309–1314.

103. Talbert LD, Kaelberer Z, Gleave E, et al. A systematic review of heart rate variability (HRV) biofeedback treatment following traumatic brain injury (TBI). Brain Injury. 2023; 37(7): 635–642.

104. Gabbett HT, Windt J, Gabbett TJ. Cost-benefit analysis underlies training decisions in elite sport. British Journal of Sports Medicine. 2016; 50(21): 1291–1292.

105. Di Pasquale S, Wood MC, Edmond R. Heart rate variability in a collegiate dance environment: Insights on overtraining for dance educators. Research in Dance Education. 2021; 22(1): 108–125.

106. Cyril B, Xavier D, Mathie S, et al. Compliance to training load and heart rate variability monitoring in young Swiss judokas. SEMS-Journal. 2023; 71(1).

107. Sánchez RP, Alonso-Pérez-Chao E, Calleja-González J, Jiménez Sáiz SL. Heart Rate Variability in Basketball: The Golden Nugget of Holistic Adaptation? Applied Sciences. 2024; 14(21): 10013.

Published
2025-02-19
How to Cite
Latino, F., Limone, P., Cassese, F. P., Martinez-Roig, R., Persico, A., & Tafuri, F. (2025). The The role of heart rate variability in the prevention of musculoskeletal injuries in female padel players. Molecular & Cellular Biomechanics, 22(3), 1350. https://doi.org/10.62617/mcb1350
Section
Article

Most read articles by the same author(s)