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Biomedical subjects

E B Simonsen

Publications and source records attributed to E B Simonsen.

At least 19 recordsLinked to original sources

Sudden loading during a dynamic lifting task: a simulation study.

It is believed that nurses risk the development of back pain as a consequence of sudden loadings during tasks in which they are handling patients. Forward dynamics simulations of sudden loads (applied to the arms) during dynamic lifting tasks were performed on a two-dimensional whole-body model. Loads were in the range of -80 kg to 80 kg, with the initial load being 20 kg. Loading the arm downwards with less than that which equals a mass of 20 kg did not change the compressive forces on the spine when compared to a normal lifting motion with a 20 kg mass in the hands. However when larger loads (40 kg to 80 kg extra in the hands) were simulated, the compressive forces exceeded 13,000 N (above 3400 N is generally considered a risk factor). Loading upwards led to a decrease in the compressive forces but to a larger backwards velocity at the end of the movement. In the present study, it was possible to simulate a fast lifting motion. The results showed that when loading the arms downwards with a force that equals 40 kg or more, the spine was severely compressed. When loading in the opposite direction (unloading), the spine was not compressed more than during a normal lifting motion. In practical terms, this indicates that if a nursing aide tries to catch a patient who is falling, large compressive forces are applied to the spine.

Adaptation, Physiological↗

Biomechanical differences in soccer kicking with the preferred and the non-preferred leg.

The aims of this study were to examine the release speed of the ball in maximal instep kicking with the preferred and the non-preferred leg and to relate ball speed to biomechanical differences observed during the kicking action. Seven skilled soccer players performed maximal speed place kicks with the preferred and the non-preferred leg; their movements were filmed at 400 Hz. The inter-segmental kinematics and kinetics were derived. A coefficient of restitution between the foot and the ball was calculated and rate of force development in the hip flexors and the knee extensors was measured using a Kin-Com dynamometer. Higher ball speeds were achieved with the preferred leg as a result of the higher foot speed and coefficient of restitution at the time of impact compared with the non-preferred leg. These higher foot speeds were caused by a greater amount of work on the shank originating from the angular velocity of the thigh. No differences were found in muscle moments or rate of force development. We conclude that the difference in maximal ball speed between the preferred and the non-preferred leg is caused by a better inter-segmental motion pattern and a transfer of velocity from the foot to the ball when kicking with the preferred leg.

Biomechanical Phenomena↗

A mechanism for increased contractile strength of human pennate muscle in response to strength training: changes in muscle architecture.

1. In human pennate muscle, changes in anatomical cross-sectional area (CSA) or volume caused by training or inactivity may not necessarily reflect the change in physiological CSA, and thereby in maximal contractile force, since a simultaneous change in muscle fibre pennation angle could also occur. 2. Eleven male subjects undertook 14 weeks of heavy-resistance strength training of the lower limb muscles. Before and after training anatomical CSA and volume of the human quadriceps femoris muscle were assessed by use of magnetic resonance imaging (MRI), muscle fibre pennation angle (theta(p)) was measured in the vastus lateralis (VL) by use of ultrasonography, and muscle fibre CSA (CSA(fibre)) was obtained by needle biopsy sampling in VL. 3. Anatomical muscle CSA and volume increased with training from 77.5 +/- 3.0 to 85.0 +/- 2.7 cm(2) and 1676 +/- 63 to 1841 +/- 57 cm(3), respectively (+/- S.E.M.). Furthermore, VL pennation angle increased from 8.0 +/- 0.4 to 10.7 +/- 0.6 deg and CSA(fibre) increased from 3754 +/- 271 to 4238 +/- 202 microm (2). Isometric quadriceps strength increased from 282.6 +/- 11.7 to 327.0 +/- 12.4 N m. 4. A positive relationship was observed between theta(p) and quadriceps volume prior to training (r = 0.622). Multifactor regression analysis revealed a stronger relationship when theta(p) and CSA(fibre) were combined (R = 0.728). Post-training increases in CSA(fibre) were related to the increase in quadriceps volume (r = 0.749). 5. Myosin heavy chain (MHC) isoform distribution (type I and II) remained unaltered with training. 6. VL muscle fibre pennation angle was observed to increase in response to resistance training. This allowed single muscle fibre CSA and maximal contractile strength to increase more (+16 %) than anatomical muscle CSA and volume (+10 %). 7. Collectively, the present data suggest that the morphology, architecture and contractile capacity of human pennate muscle are interrelated, in vivo. This interaction seems to include the specific adaptation responses evoked by intensive resistance training.

Adult↗

Soleus H-reflex gain in humans walking and running under simulated reduced gravity.

The Hoffmann (H-) reflex is an electrical analogue of the monosynaptic stretch reflex, elicited by bypassing the muscle spindle and directly stimulating the afferent nerve. Studying H-reflex modulation provides insight into how the nervous system centrally modulates stretch reflex responses.A common measure of H-reflex gain is the slope of the relationship between H-reflex amplitude and EMG amplitude. To examine soleus H-reflex gain across a range of EMG levels during human locomotion, we used simulated reduced gravity to reduce muscle activity. We hypothesised that H-reflex gain would be independent of gravity level.We recorded EMG from eight subjects walking (1.25 m s-1) and running (3.0 m s-1) at four gravity levels (1.0, 0.75, 0.5 and 0.25 G (Earth gravity)). We normalised the stimulus M-wave and resulting H-reflex to the maximal M-wave amplitude (Mmax) elicited throughout the stride to correct for movement of stimulus and recording electrodes relative to nerve and muscle fibres. Peak soleus EMG amplitude decreased by ~30% for walking and for running over the fourfold change in gravity. As hypothesised, slopes of linear regressions fitted to H-reflex versus EMG data were independent of gravity for walking and running (ANOVA, P > 0.8). The slopes were also independent of gait (P > 0.6), contrary to previous studies. Walking had a greater y-intercept (19.9% Mmax) than running (-2.5% Mmax; P < 0.001). At all levels of EMG, walking H-reflex amplitudes were higher than running H-reflex amplitudes by a constant amount. We conclude that the nervous system adjusts H-reflex threshold but not H-reflex gain between walking and running. These findings provide insight into potential neural mechanisms responsible for spinal modulation of the stretch reflex during human locomotion.

Adult↗

Contraction-specific differences in maximal muscle power during stretch-shortening cycle movements in elderly males and females.

Elderly people (age 75 years; n = 48 males and 34 females) were studied in order to elucidate gender differences in elderly subjects on the determinants of muscle power (force and velocity) during a stretch-shortening cycle. All subjects performed three maximal counter-movement vertical jumps using both legs, on a force platform (Kistler 9281 B). The eccentric (Ep) and concentric (Cp) phases of the jumps were analyzed. The Ep was further divided into an acceleration phase (Epacc: from the start of the downward movement to the maximal negative velocity) and deceleration phase (Epdec: from the maximal negative velocity to the end of the downward movement). Jump height for the men was higher than for the women (P < 0.001). During both Epacc and Epdec no significant differences were observed between males and females in force and power generation. However, the men had a higher peak muscle power during the Cp, which may be explained exclusively by the velocity determinant (P < 0.001). No specific gender-related strategy appeared to influence the motor pattern of the movement. The comparable eccentric force generation of the leg extensors in both genders suggests a similar ability to cope with eccentric muscle actions during everyday activities. In contrast, the marked lower capacity for concentric contractions in women may result in an impaired performance, especially in activities where intense and rapid movements are essential, for example when reversing a forward fall. This may be one reason why elderly women are more prone to falls than are elderly men.

Accidental Falls↗

Comparison of inverse dynamics calculated by two- and three-dimensional models during walking.

The purpose of the study was to compare joint moments calculated by a two- (2D) and a three-dimensional (3D) inverse dynamics model to examine how the different approaches influenced the joint moment profiles. Fifteen healthy male subjects participated in the study. A five-camera video system recorded the subjects as they walked across two force plates. The subjects were invited to approach a walking speed of 4.5 km/h. The ankle, knee and hip joint moments in the sagittal plane were calculated by 2D and 3D inverse dynamics analysis and compared. Despite the uniform walking speed (4.53 km/h) and similar footwear, relatively large inter-individual variations were found in the joint moment patterns during the stance phase. The differences between individuals were present in both the 2D and 3D analysis. For the entire sample of subjects the overall time course pattern of the ankle, knee and hip joint moments was almost identical in 2D and 3D. However, statistically significant differences were observed in the magnitude of the moments, which could be explained by differences in the joint centre location and joint axes used in the two approaches. In conclusion, there were differences between the magnitude of the joint moments calculated by 2D and 3D inverse dynamics but the inter-individual variation was not affected by the different models. The simpler 2D model seems therefore appropriate for human gait analysis. However, comparisons of gait data from different studies are problematic if the calculations are based on different approaches. A future perspective for solving this problem could be to introduce a standard proposal for human gait analysis.

Adult↗

Kinetics and energetics during uphill and downhill carrying of different weights.

During physically heavy work tasks the musculoskeletal tissues are exposed to both mechanical and metabolic loading. The aim of the present study was to test a biomechanical model for prediction of whole-body energy turnover from kinematic and anthropometric data during load carrying. Total loads of 0, 10 and 20 kg were carried symmetrically or asymmetrically in the hands, while walking on a treadmill (4.5 km h(-1)) horizontally, uphill, or downhill the slopes being 8%. Mean values for the directly measured oxygen uptake ranged for all trials from 0.5 to 2.1 l O2 min(-1), and analysis of variance showed significant differences regarding slope, load carried, and symmetry. The calculated values of oxygen uptake based on the biomechanical model correlated significantly with the directly measured values, fitting to the line Y = 0.990 X + 0.144, where Y is the estimated and X is the measured oxygen uptake in l min(-1). The close relationship between energy turnover rate measured directly and estimated based on a biomechanical model justifies the assessment of the metabolic load from kinematic data.

Adult↗

Antagonist muscle coactivation during isokinetic knee extension.

The aim of the present study was to quantify the amount of antagonist coactivation and the resultant moment of force generated by the hamstring muscles during maximal quadriceps contraction in slow isokinetic knee extension. The net joint moment at the knee joint and electromyographic (EMG) signals of the vastus medialis, vastus lateralis, rectus femoris muscles (quadriceps) and the biceps femoris caput longum and semitendinosus muscles (hamstrings) were obtained in 16 male subjects during maximal isokinetic knee joint extension (KinCom, ROM 90-10 degrees, 30 degrees x s(-1)). Two types of extension were performed: [1] maximal concentric quadriceps contractions and [2] maximal eccentric hamstring contractions Hamstring antagonist EMG in [1] were converted into antagonist moment based on the EMG-moment relationships determined in [2] and vice versa. Since antagonist muscle coactivation was present in both [1] and [2] a set of related equations was constructed to yield the moment/EMG relationships for the hamstring and quadriceps muscles, respectively. The equations were solved separately for every 0.05 degrees knee joint angle in the 90-10 degrees range of excursion (0 degrees = full extension) ensuring that the specificity of muscle length and internal muscle lever arms were incorporated into the moment/EMG relationships established. Substantial hamstring coactivation was observed during quadriceps agonist contraction. This resulted in a constant level of antagonist hamstring moment of about 30 Nm throughout the range of motion. In the range of 30-10 degrees from full knee extension this antagonist hamstring moment corresponded to 30-75% of the measured knee extensor moment. The level of antagonist coactivation was 3-fold higher for the lateral (Bfcl) compared to medial (ST) hamstring muscles The amount of EMG crosstalk between agonist-antagonist muscle pairs was negligible (Rxy2<0.02-0.06). The present data show that substantial antagonist coactivation of the hamstring muscles may be present during slow isokinetic knee extension. In consequence substantial antagonist flexor moments are generated. The antagonist hamstring moments potentially counteract the anterior tibial shear and excessive internal tibial rotation induced by the contractile forces of the quadriceps near full knee extension. In doing so the hamstring coactivation is suggested to assist the mechanical and neurosensory functions of the anterior cruciate ligament (ACL).

Adult↗

Motor pattern of the knee joint muscles during side-step cutting in European team handball. Influence on muscular co-ordination after an intervention study.

The incidence of anterior cruciate ligament (ACL) injuries is reported to be high in many popular team sports The most risky movement in European team handball is reported to be the side-step cutting manoeuvre. Well-rehabilitated ACL-deficient athletes have been shown to have increased co-contraction about the knee joint with this manoeuvre. The aim of this study was to examine the effect of a prophylactic training programme on the co-contraction of the knee joints of non-injured European team handball players The subjects performed 'match-like' cutting manoeuvres on a force platform. EMG-signals from the involved knee joint muscles and force platform signals were simultaneously stored on a personal computer. The data collected before and after a 12-week prophylactic training program were compared. The results demonstrated that rehabilitation exercises cannot increase co-contraction about the knee joint in healthy athletes during side-step cutting. This is contradictory to the reported effect on ACL-deficient athletes.

Adult↗

Can the hamstring muscles protect the anterior cruciate ligament during a side-cutting maneuver?

Because anterior cruciate ligament (ACL) injuries are common in European handball the present study assessed knee joint shear forces to estimate ACL loading in six elite female handball players during a side-cutting maneuver. A pilot investigation in three dimensions showed that peak moments occurred in the sagittal plane at a high velocity. Therefore, analysis of the movement was performed in two dimensions using high-speed cinematography, ground reaction forces, and electromyography (EMG). Film and force plate data allowed for calculation of net joint moments (inverse dynamics), estimates of instantaneous muscle-tendon lengths, contraction velocities, and peak loading of the ACL. During the breaking phase of the maneuver the peak knee joint moment was 239 Nm (99-309), which yielded an ACL-load of 520 N (215-673). The corresponding peak EMG amplitudes for the hamstring muscles were 34-39% of maximum EMG. During the breaking phase the quadriceps muscle contracted eccentrically with a velocity of 216-253% fiber length/s. In contrast, the hamstring muscles contracted concentrically with a velocity of 222-427% fiber length/s. These results suggest that a side-cutting maneuver produces loads that are insufficient to rupture the ACL. Furthermore, the rapid concentric hamstring contraction suggests that even during maximal activation, the ability of the hamstrings to reduce the ACL load is marginal.

Adult↗

Passive tensile stress and energy of the human hamstring muscles in vivo.

The present study measured passive resistance to stretch in the hamstring muscles during a standardized stretch maneuver to estimate tensile forces and energy of the individual hamstring muscles in 7 flexible and 6 inflexible persons defined according to joint range of motion. Using a dynamometer, knee joint moment was measured during slow passive knee extension to a maximal angle (dynamic phase) followed by a 90-s static phase. Cross-sectional areas (CSA) of the separate hamstring muscles were obtained with magnetic resonance (MR) imaging. Mathematical modeling was used to calculate instantaneous muscle length and joint moment arm for each muscle. Subsequently, passive muscle tension (N/cm2) was calculated based on moment arm lengths, knee joint moments, and CSA. Maximal tolerated joint angle was greater in flexible (delta1.30+/-0.06 rad) than inflexible (delta0.84+/-0.06 rad) subjects, P<0.01. The peak tension at maximal angle was greater in flexible (81.8+/-12.5 N/cm2) than inflexible subjects (29.3+/-4.1 N/ cm2), P<0.001. For the separate muscles the overall change in muscle length (delta cm) and moment arm (delta cm) differed between groups, P<0.01. Similarly, muscle stiffness (delta tension/delta muscle length) was greater in flexible than inflexible subjects in the final 3 cm, P<0.01, and in the final 20% of length change, P<0.01. Absorbed energy (mJ/cm2) was greater in flexible than inflexible subjects in the final 40% of length change, P<0.05. These data show that flexible persons can attain a greater angle of stretch with an accompanying greater tensile stress and energy than inflexible persons due to an apparent greater tolerance to the externally applied load, and larger change in moment arm. The obtained stress data appear to be in the toe region of a 'classical' stress-strain curve, and energy rather than stiffness may therefore be more appropriate to analyze during the stretch procedure.

Adult↗

Neural inhibition during maximal eccentric and concentric quadriceps contraction: effects of resistance training.

Despite full voluntary effort, neuromuscular activation of the quadriceps femoris muscle appears inhibited during slow concentric and eccentric contractions. Our aim was to compare neuromuscular activation during maximal voluntary concentric and eccentric quadriceps contractions, hypothesizing that inhibition of neuromuscular activation diminishes with resistance training. In 15 men, pretraining electromyographic activity of the quadriceps muscles [vastus medialis (VM), vastus lateralis (VL), and rectus femoris (RF)] was 17-36% lower during slow and fast (30 and 240 degrees/s) eccentric and slow concentric contractions compared with fast concentric contractions. After 14 wk of heavy resistance training, neuromuscular inhibition was reduced for VL and VM and was completely removed for RF. Concurrently, electromyographic activity increased 21-52, 22-29, and 16-32% for VL, VM, and RF, respectively. In addition, median power frequency decreased for VL and RF. Eccentric quadriceps strength increased 15-17%, whereas slow and fast concentric strength increased 15 and 8%, respectively. Pre- and posttraining median power frequency did not differ between eccentric and concentric contractions. In conclusion, quadriceps motoneuron activation was lower during maximal voluntary eccentric and slow concentric contractions compared with during fast concentric contraction in untrained subjects, and, after heavy resistance training, this inhibition in neuromuscular activation was reduced.

Adult↗

Amplitude of the human soleus H reflex during walking and running.

1. The objective of the study was to investigate the amplitude and modulation of the human soleus Hoffmann (H) reflex during walking and during running at different speeds. 2. EMGs were recorded with surface electrodes from the soleus, the medial and lateral head of the gastrocnemius, the vastus lateralis and the anterior tibial muscles. The EMGs and the soleus H reflex were recorded while walking on a treadmill at 4.5 km h-1 and during running at 8, 12 and 15 km h-1. 3. The amplitudes of the M wave and the H reflex were normalized to the amplitude of a maximal M wave elicited by a supramaximal stimulus just after the H reflex to compensate for movements of the recording and stimulus electrodes relative to the nerve and muscle fibres. The stimulus intensity was set to produce M waves that had an amplitude near to 25 % of the maximal M wave measured during the movements. As an alternative, the method of averaging of sweeps in sixteen intervals of the gait cycle was applied to the data. In this case the amplitude of the H reflex was expressed relative to the maximal M wave measured whilst in the standing position. 4. The amplitude of the H reflex was modulated during the gait cycle at all speeds. During the stance phase the reflex was facilitated and during the swing and flight phases it was suppressed. The size of the maximal M wave varied during the gait cycle and this variation was consistent for each subject although different among subjects. 5. The peak amplitude of the H reflex increased significantly (P = 0.04) from walking at 4.5 km h-1 to running at 12 and 15 km h-1 when using the method of correcting for variations of the maximal M wave during the gait cycle. The sweep averaging method showed a small but non-significant decrease (P = 0. 3) from walking to running at 8 km h-1 and a small decrease with running speed (P = 0.3). The amplitude of the EMG increased from walking to running and with running speed. 6. The relatively large H reflex recorded during the stance phase in running indicates that the stretch reflex may influence the muscle mechanics during the stance phase by contributing to the motor output and enhancing muscle stiffness.

Adult↗

Anatomical differences in the psoas muscles in young black and white men.

The anatomy of the psoas major muscle (PMA) in young black and white men was studied during routine autopsies. The forensic autopsies included 44 fresh male cadavers (21 black, 23 white) with an age span of 14 to 25 y. The range for weight was 66-76 kg and for height 169-182 cm. The PMA was initially measured in its entire length before measuring the diameter and circumference at each segmental level (L1-S1). At each segmental level, the calculated anatomical cross-sectional area (ACSA) was more than 3 times greater in the black group compared with the white (P < 0.001). The psoas minor muscle (PMI) was absent in 91% of the black subjects, but only in 13% of the white subjects. These data show that the PMA is markedly larger in black than white subjects. The marked race specific difference in the size of the PMA may have implications for hip flexor strength, spine function and race specific incidence in low back pathology, and warrants further investigation.

Adolescent↗

EMG activity of the iliopsoas muscle and leg kinetics during the soccer place kick.

The purpose of the study was to develop a method to record intramuscular electromyogram (EMG) from the iliopsoas muscle and to relate this activity to the kinetics during the soccer place kick. Seven skilled soccer players performed 3 maximal velocity place kicks. The kicks were filmed with a high-speed camera (400 Hz) and EMG recordings were obtained from 5 muscles of the kicking leg, including wire electrodes inserted into the m. iliopsoas. The EMG signals were compared to the kinetics of the kicking leg, which were calculated from the digitised film. The results showed hardly any torque reversal about the hip joint before impact. Angular deceleration of the thigh segment did not increase the angular velocity of the shank (work -3.57 to 0.0%). M. iliopsoas was active during the entire kicking motion (average EMG 65.1-100.9%), even in the period when the thigh was decelerating. Wire electrodes can successfully be applied to EMG recordings of fast unloaded movements.

Adult↗

Choice of jumping strategy in two standard jumps, squat and countermovement jump--effect of training background or inherited preference?

Six male subjects, three professional ballet dancers and three elite volleyball players, performed maximal vertical jumps from 1) a static preparatory position (squat jump), 2) starting with a countermovement (countermovement jump) and 3) a specific jump for ballet and for volleyball, respectively. The jumps were recorded on highspeed film (500 Hz) combined with registration of ground reaction forces, and net joint moments were calculated by inverse dynamics. The purpose was to investigate the choice of strategy in two standard jumps, squat jump and countermovement jump. The volleyball jump was performed with a sequential strategy and the ballet jump was performed with a simultaneous strategy. In the two standard jumps, the choice of strategy was individual and not related to training background. This was additionally confirmed in a test of seven ballet dancers and seven volleyball players.

Biomechanical Phenomena↗

Modulation of short latency stretch reflexes during human hopping.

To gain insight into central and peripheral reflex control mechanisms in moving humans we have investigated short latency stretch reflex activity in m. triceps surae during two legged hopping. The objectives were: (1) to compare movement induced short latency stretch reflexes in soleus and medial gastrocnemius (MG) muscles, (2) to determine the relationship between the size of these reflexes and the muscle spindle stretch velocities, and (3) to compare the size of the movement induced short latency stretch reflexes and the H-reflexes simultaneously. Six well-trained healthy male subjects participated and they hopped at three different work rates. Surface electromyogram (EMG) and H-reflexes were recorded during hopping. Muscle spindle length changes were estimated as the difference between estimated origin-to-insertion length changes and tendon length changes. The important findings were that during hopping: (1) movement induced short latency stretch reflexes were observed consistently in soleus, (2) the EMG amplitude of this stretch reflex was negatively correlated with the estimated peak muscle spindle stretch velocity (rs = -0.52, P < 0.02), and (3) the amplitude of the soleus H-reflex at touchdown did not change in parallel with the stretch reflex. The negative correlation observed between the stretch reflex and the estimated peak muscle spindle stretch velocity in soleus is opposite to the basic velocity sensitive behaviour of stretch reflexes mechanically elicited during resting conditions. Possible control mechanisms are discussed. Additionally, muscle spindle length changes estimated from changes in the skeletal movements (joint angles) should be inferred cautiously because of tendon compliance, especially at high tendon forces.

Adult↗

Isokinetic muscle strength and hiking performance in elite sailors.

The aim of the present study was to describe the isokinetic strength profile and its relation to hiking performance in male (SM, n = 15) and female (SF, n = 6) elite sailors compared to a group of male control subjects (CM, n = 8) similar in age, anthropometry and level of fitness. Eccentric knee extension strength was higher in SM compared to CM (P < 0.01). Furthermore, SM were stronger during trunk extension (P < 0.05), but not during trunk flexion compared to CM. Overall muscle strength was lower in SF compared to SM (P < 0.01) and CM (P < 0.05), except for eccentric knee extension strength, where SF and CM did not differ (P > 0.05). Hiking performance correlated to maximal eccentric and isometric knee extensor strength in SF (rs = 0.83-0.88, P < 0.05) and in CM (rs = 0.73-0.77, P < 0.05) and to maximal eccentric knee extensor strength at high velocity in SM (rs = 0.46-0.54, P < 0.05). For a subgroup of hikers in SM (n = 8), hiking performance correlated to maximal isometric-eccentric knee extensor strength (rs = 0.67-0.74, P < 0.05), whereas no correlations emerged for the non-hikers (n = 7). Few correlations were observed between hiking performance and maximal concentric trunk flexor strength (rs = 0.69-0.92, P < 0.05). Unexpectedly, in SM correlations also were observed between hiking performance and maximal strength of the trunk extensors (rs = 0.46-0.53, hiker subgroup: rs = 0.64-0.67, P < 0.05). In conclusion, notably high levels of maximal eccentric knee extensor strength were observed for the male and female elite sailors examined in the present study. Furthermore, the present results suggest that hiking performance depends in part on maximal isometric-eccentric knee extensor strength. The maximal strength of the trunk extensors, which potentially stabilizes the lower back and spine, also seems to have some importance for the hiking performance of top-level sailors.

Adult↗