**3. Current findings exploring resistance movement activities in and around the curriculum**

Strength-related activities improve daily function and self-esteem children varied in functional gross motor proficiency [52]. In regards to biomotor abilities (strength, endurance, speed, flexibility and coordination), children and youth made significant improvements across aerobic endurance, strength endurance, flexibility and body composition (as indirectly measured through waist-to-height ratio) when implementing the program twice weekly as is and once weekly through an educational games version as measured using the FITNESSGRAM [53]. **Tables 3–7** depict the number of participants across the control and three groups using the program through differing pedagogies. All four groups participated in daily physical education classes across the academic year and participated in the pre- and post-experimental implementation. Each enumerated grouping (1–4) included several classes from both one elementary and one secondary school setting. Groups 2, 3 and 4 all experienced significant improvements in their biomotor fitness components. Those from the control experienced a significant reduction. Results depict between participant effects. Means are displayed to denote any changes between pre- and post-daily physical education curricular programmes, three of which were dedicated to the biomotorfocused resistance program. Following the attainment of institutional and school

district ethical permissions, elementary and middle schools volunteered to participate. The eight schools were randomly assigned to training (three cohorts of 250; n = 750) as implemented using a variety of more direct to less direct teaching styled choices and one cohort as control (N = 250). All groups participated in daily PE (60 minutes). Those in the control group participated in the respective school curriculum and dedicated two days weekly to fitness-related activity. Those in the training groups participated in the resistance exercise program across two (out of five) lessons in their curriculum. All schools provided games-focused activities across the remainder days (court and field games). The main outcomes found significant improvement in biomotor competencies (as measured through the FITNESSGRAM). Cohorts across a series of state elementary and secondary schools participated through control and three pedagogical iterations of the resistance program to explore tutor and participant preference. The direct teaching group (n = 201) demonstrated significantly improved scores across fitness biomotor competencies measured (z = 5.763, p < 0.001). Those in the inquiry-based cohort (n = 174) significantly improved their fitness (z = 4.439, p < 0.001). Pupils within the combined group of resistance as delivered through

#### **Table 3.**

*Mean changes from pre (1) to post (2) measurement across four groups (elementary and secondary student combinations) in the treatment of biomotor fitness components through three differing pedagogical iterations implementing the same content program content, competencies and knowledge.*

#### **Table 4.**

*Mean score and change across questions around self-management (metacognition) of physical activity.*

**Table 5.**

*Score changes between the pre- and post-self-management measurement.*

#### **Table 6.**

*Motivation pre and post change.*

**Table 7.**

*Mean score and change in score, all motivation questions combined.*

direct–indirect combination teaching method (n = 135) demonstrated significant improvements across the collective fitness regimen (z = 6.902, p < 0.001). Pupils in the control group (n = 162) did not improve their fitness. This reduced significantly (z = 3.675, p < 0.001) (**Table 3**).

Following this inquiry, it became imperative to explore how to maximise physical education (PE) provision for settings where the academic subject was provided limited time (twice weekly). Therefore, if PE allocated time could not encompass adequate time to improve biomotor fitness, it could arguably be used to prepare children and to motivate them to learn how to use such skills in ways they found enjoyable in and beyond PE. This function was integrated into the next research series, linking curricular PE to recess physical activity. Institutional and local authority ethical permissions were sought and attained for this quasi-experimental study. Participating schools in South England incorporated explicit teaching to participating children and youth on how to exercise and perform the moves safely and effectively. Basic skills were introduced, explained and modelled during PE through teacher-led sequences. Explicit attention was provided to the explicit training of educators and interested (student) participants for recess time peer-initiated participation following the introduction and practice of the skills in PE time. Both motivations to join in and continue this beyond class time, together with knowledge of how to execute and regulate self-participation significantly improved as measured through developmentally appropriate intrinsic motivation and metacognitive awareness inventories [3, 54]. Participants significantly improved declarative, procedural and contextual knowledge around the skills and competencies acquired in PE and then transferred to extracurricular peer-led physical activity following a five-month intervention (x = 0.400, n = 6226, p < 0.001). Awareness of how to use resources beyond the PE setting learning was significantly higher in the post-condition compared to the pre-condition (z = 22.86, r = 0.29, p < 0.001). Unlike that of the directed PE time, when scaffolded in a way that opened participant choice of how and when the resistance challenges were used, motivation to participate during lunchtime, with peer invitation and support increased. In all participants there was a larger number whose score increased (mean s.e. = 195 8.37) than decreased (129 3.82) although the majority of scores stayed the same (367 7.41).

Metacognition was measured. Findings show that the level of participant metacognitive awareness, with regard to their use of the playground markings, increased from the beginning to the end of the study and that this difference was statistically significant (x = 0.400, n = 6226, p < 0.001) [55]. Scores were significantly higher post-treatment compared to pre-treatment in both function groups although the effect size was larger for regulation of cognition (Wilcoxon Signed Rank test: z = 13.78, r = 0.25, p < 0.001) than it was for knowledge of cognition (z = 18.26, r = 0.33, p < 0.001). Consistent with this, the regulation cognition group of questions were associated with a substantially larger number and proportion of increases in response score from pre- to post-treatment than were the knowledge of cognition question. The mean knowledge of cognition scores were higher than the mean regulation of cognition scores both pre- (Knowledge: 2.60' Regulation: 2.23) and post (Knowledge: 2.73; Regulation: 2.46) treatment but the change in score was greater for regulation of cognition (Regulation +0.22; Knowledge: +0.13) (**Tables 4** and **5**).

Motivation to participate using a variety of moves in student-directed ways during lunch was appraised via the motivation scores. These scores were significantly higher in the post-condition compared to the pre-condition and when the questions were considered separately, scores were significantly higher post-treatment compared to pre-treatment in five out of the seven questions. In all cases, there was a larger number of students whose score increased (mean s.e. = 195 8.37) than decreased (129 3.82) although the majority of scores stayed the same (367 7.41). (**Tables 6** and **7**). Unsurprisingly opportunities to share some ownership of how such a program is to be experienced in conjunction with 'the what' of it, make for a welcome pedagogical inclusion [56].

To date, it is plausible that curricular time can be effectually used to introduce the skills and competencies needed for children to gain motor competence and fitness. However, creative means to facilitate other ways to participate are found to have been of value for children to use these meaningfully at their own discretion.

The 'I Can Resist' program takes explicit steps to build in structured choice and to facilitate peer support and self-agentic opportunities. Access in this regard shifts intended outcomes toward the facilitation of independent movers who can use, adapt and/or extend the resistance exercises into meaningful individual or group endeavours at their respective discretion ahead of motor proficiency outcomes. The latter progresses at the pace of each participant.

## **4. The 'I Can Resist' program**

I Can Resist commences with resistance moves that are practised, refined and acquired through isometric challenges and then progressed through concentriceccentric contractions and increase in number and complexity. The use of the 1st pronoun is to model and communicate and ensure the doing, and learning is done by each participant. That tactic also keeps the pace participant led. The spiral of progression (**Table 8**) reads from bottom to top and incorporates movement concepts so that participants have the opportunity to try the skills in a variety of ways that build understanding through interpretation of movement concepts. Mastery-wise, participants work their way through the bodyweight (only) progression spiral before they continue with added band resistance challenges. Further along the proficiency journey, participants can actually return (revisit) the progression spiral (**Table 8**. exemplification) and work their way through it incorporating resistance band

challenges in ways found accessible and enjoyable. However, it is essential that participants work their way through the spiral managing only their own body weight first and foremost, before progressing onto the resistance movement skill series (**Tables 1** and **2**). Pedagogical tips are provided and discretional. They serve simply as a userfriendly optional guide. Clearly, this can be used and adapted to fit desired goals and expectations across a varied series of settings. The program has emerged from its original piloted three-step method incorporating the body, the resistance band and the suspension trainer as modes of improving biomotor fitness [57–59].

#### **4.1 Health and safety guidelines**

Health and safety remain consistent across each and all. Ensure respective health and safety policies and guidelines are adhered to across the planning and implementation and evaluation of program use. Participation remains student dependent and centred. Adapt to the known and emerging needs of the individual/group. Provide equitable, transparent and engaging ways the student can assist in your being effective in the provision and presentation of accessible learning opportunities. Rest and water breaks are also student centred and directed.

• I can hold a plank for a set target time (10–30 secs) and move my feet and then hands (one at a time)

#### **Table 8.**

*The 'I Can Resist' introductory progression spiral.*

### *4.1.1 Pedagogical tip*

*Fitness tip—do not make it about fitness! Keep it task/challenge oriented and match the language to show the genuine tutor focus of motor competence—agility development through balance and control.*

Inclusion target: Start somewhere, anywhere, for example, with a short 5–10 secs hold, and/or show a peer that takes even less but gets participants moving and trying and exploring and managing their bodies through a progression that takes them from high to medium and low levels, exploring personal space through basic moves, in a variety of ways. Progress using limited repetitions (or short-time bouts). That way peer modelling happens inadvertently and explicitly and attempts to stay task focused (rather than fitness). The way it is done.

\*Can be revisited with a resistance band for the more experienced mover.

### *4.1.2 Pedagogical tip*

*Work your way through these by modelling and providing a brief explanation as you go. Keep all group members active and work your way up. Once you get to the top, start back again and repeat this time, change.*

**Table 8** depicts how the program is introduced. Explicit opportunities to develop motor competence manipulating the body in a variety of ways, at different levels to engage all major muscle groups are presented. Differing ways to develop social competence are integrated into the movement's challenges. Participants need to draw from cognitive, emotional and social skills to work their way through the progression spiral. The tutor initiates each new competence and skill through direct teaching and then facilitates greater inquiry-led challenges when students have something to access and try and something to talk about in their exchange.

Once participants have journeyed through the spiral, the resistance movement bank (**Tables 1** and **2**) can be utilised and drawn from to support the next progression spiral iterations. Tutors will want to show and tell each, as regards their utility, how they are done and exploring these across a variety of opportunities. If initiated from the outset of elementary years, a curriculum map can plot how and where and when the resistance skills, sequences and activities are interleaved into the full curriculum spiral, whereby competence, confidence and concomitant motor creativity are developmentally facilitated across a full six-year journey, for example. Tutors are well apt to make use of affordances as depicted through respective curricular and extracurricular chances.

#### **4.2 Developmentally appropriate question—With or without bands?**

Use the 'flag lunge'stability challenge across the sessions. If pupils struggle with this essential stability move (See formative assessment within item #3), provide bandfree versions and as well as adapt as required. You can use any of the movement challenges from the resistance movement resource bank (#1–22). A worked example of how to use it following the movement induction is depicted in **Table 9**. Of course, this is but a linear rendition. Contextual educational topic choices with desired themes will readily modify if not replace this.

#### *4.2.1 Pedagogical replace*

*Have biomotor fitness as a by-product instead of the actual focus. Encore une fois—Do not make it about fitness! A progression learning spiral is exemplified and participants have patiently progressed through this. You have also shown patience with term use and modelled and explained how to get here. Take advantage of this.*

#### **4.3 The 'I Can Resist' summary**

Make it work for you and for your group. To be learned, it does need to be tried, understood and appreciated with plenty of chances to try and take calculated risks in figuring movement and verbal responses to challenges through less to more invariant opportunities.

#### **4.4 Plenary**

The premise behind 'I Can Resist' is that we, educators, can make resistance exercise meaningful and enjoyable for a wide variety of children and youth. One story that motivated the creation of this invitational approach remains with me today. One PE day, during a dedicated activity period of the lesson, a grade 4 student ran to me and was crying because he had never before felt his heart beating so hard through his

assessment to top and tail your own scope and sequence, for example, a six-lesson medium-term plan—modify to fit as a means to inform students of their own progress and for you to be able to have this.

*This exemplified scope and sequence follow the introductory body and self-management progression spiral (Table 3 content). It uses resistance movement vocabulary from Tables 1 and 2. Students and educators can take ownership to use the movement vocabulary in a meaningful way to suit the intention and aspirations of the class and learning experience. Greater ownership and creativity can emerge using ideas such as those through the progression spiral challenge ideas (Table 3-pedagogical progression).*

#### **Table 9.**

*A basic rendition of starting resistance moves around the contextually relevant educational themes, topics and aims can be built.*

chest. I locked eyes with him, smiled and gently encouraged him to walk with me as his heart rate came down. I learned never again, to assume that all children are wired to move and move with vigour. The role of the other, the parent, the guardian and the peer, compelled me to develop means for children to become agentic alongside respective environmental factors, and hopefully irrespective of these where, and when they lacked opportunity for positive progression. The other part of my lesson learned of course is to make more efforts to offer joyful ways for the heart to soar and, educationally, to make this count. Now with my colleagues, we are able to progress such inclusive and aspirational practices in more accessible ways.

#### **Acknowledgements**

Thank you, colleagues, for your commitment to building an array of valuable life skills and competencies through the bold implementation of the 'I Can Resist' in your own contexts, starting right from the beginning... My sincere thanks to colleagues and students from and found around the world, to my pole vault peer and my daughter for giving of their time to try out the program and capture these efforts in a simple and accessible way, as depicted in the start-up resistance movement bank (**Tables 1** and **2**). To my esteemed colleagues Dr. Kristy Howells and Dr. Pamela Murray for the next exciting and emerging steps as we take 'I Can Resist' and explore movement possibilities with our students as we build body strength, identity and belonging.


**1. Introduction**

Heavy metals, the name has so many definitions based on various parameters. Based on density the metals which are having a density values greater than 5 g/cm3 are considered as heavy metals [1]. According to this study, the heavy metals which would consider as most threat to human beings are lead, cadmium, mercury, and arsenic. Duffs [2] reviewed the usage of the term heavy metals from the history and finally, he concluded that using the term "heavy metals" is meaningless. He established that there is no relation between the density of the metal and to the usage of the term. In the case of heavy metals, metalloid arsenic also included, from this the term heaviness means may be toxicity.

Some of the heavy metals are having so much of biological importance in trace amounts [3] particularly the elements that are present in the 4th period in the modern periodic table. The biological importance of these metals is enzyme functioning (vanadium and manganese), hormone functioning, production (selenium), cellular growth (nickel), and metabolic growth (arsenic). But these metals are required for the human in trace amounts only if their amount in the body increases they cause adverse effects on human health. Overall the heavy metal should be considered as having high density and also biological importance in trace amounts.

There is a lot of importance for the determination of heavy metals in the various environmental segments, such as air, water, and soil due to their carcinogenic and toxic nature. The IARC (International Agency for Research on Cancer) declared arsenic, hexavalent chromium, cadmium, and nickel and their compounds as

group 1 carcinogens (proven carcinogens). Arsenic and their compounds cause urinary bladder, liver, and lung cancers. Hexavalent chromium causes lung cancer and nickel and its compounds cause nasal cavity and lung cancers. All these elements cause cancers to human beings by the route of exposure is through inhalation and ingestion [4]. Regarding the availability of various heavy metals in the earth's crust is about 5%, among which iron occupies nearly 95% [5].

Due to their toxicity and carcinogenic nature, most of the researchers all over the world are reported about the determination and health implications of heavy metals in the environment. Some of them are discussed hereunder.

Jyothi and Mohamed Farook [6] reported the sources, exposure, and toxicity of mercury. Suvarapu et al. [7] reviewed the heavy metal concentrations in ambient air. This study is limited to the estimation of toxicity of heavy metals in the Indian atmosphere and another study [8] they reviewed the heavy metal determination in ambient air all over the world. Kim et al. [9] reviewed heavy metal toxicity and chelating therapeutic strategies. Giller et al. [10] reviewed the toxicity of heavy metals in microorganisms in agricultural soils. This study found that the microorganisms in soil are much sensitive to heavy metal toxicity than animals and plants. Yabe et al. [11] summarized heavy metal pollution and its impact on the environment and the human population in Africa. Das et al. [12] reviewed the toxicity of cadmium in plants. Proshad et al. [13] reviewed the toxicity of heavy metals in soils of Bangladesh. In this study, they concentrated on the impact of industrialization on the concentration of heavy metals in soil. Su et al. [14] reported the heavy metal contamination in soil worldwide. In this study, they mentioned the current situation of contamination and remediation methods.

The present chapter describes the heavy metal sources, exposure, and the impact of their toxicity on various environmental segments. Based on the toxicity and nonbiodegradable nature of lead, cadmium, mercury, and arsenic, the present study mainly focused on these metals.


*4.1. Patient Characteristics*

The clinical characteristics of the 233 included patients are summarized in Table 1. From 2015 to 2018, 233 patients for staging and restaging were retrospectively evaluated. [68Ga]Ga-PSMA-11 PET/CT of 215 BC patients who had previously undergone either radical prostatectomy (178, patient group P-P, PSA elevation to >0.2 ng/mL by definition) or radiation therapy (37, patient group P-I, PSA elevation to >2 ng/mL above nadir by definition) and 18 patients with elevated PSA serum level of >4.0 ng/mL, highly suspicious of having primary PCa (group P-T) were separately assessed [15]. All PSMA-positive lesions of P-T were histopathologically confirmed as PCa by biopsy. In case of BC (P-P, P-I), when the biopsy or surgery of PSMA-avid lesions was not possible or considered too invasive for the patients (e.g., bone metastases), we rated the increase of PSA before therapy and decrease after therapy as a tumor confirmation and marker. Additionally, we have included the findings of follow-up examinations (such as PSMA PET/CT, PSMA PET/MRI, CT, MRI).

This retrospective study was done in accordance with the Declaration of Helsinki. All reported investigations were conducted according to the national regulations (German Medical Products Act, AMG § 13.2b). The protocol was approved by the Ethics Committee of Laek Rlp (2018-13390). All patients signed an informed consent (including participation in the study and for evaluation and publication of their anonymized data).


**2. Methods**

The ED and UCC studied were situated in a hospital in Gothenburg in western Sweden. The ED was part of a University Hospital, distributed over three main hospital complexes in di fferent districts, with one ED each. Each of the EDs received approximately one-third of the 150,000 presentations annually in the city. The ED included was typical, i.e., treating diseases and injuries from age 16, excluding orthopaedic and psychiatric diseases. It received 53,840 visits during 2018, an increase of 4.8% over the year before (2017). The trend of more visits had been apparent during the last few decades. The ED served the part of the county characterised by the weakest socioeconomic status and highest proportion of immigrants. A UCC was established in spring 2018, sta ffed with primary care physicians and registered nurses. The UCC shared the triage line with the ED, with attendees being assessed post-triage as either ED or UCC patients. The UCC was expected to optimise shared resources and provide improved services for low-urgency patients. The study was approved by the Regional Ethical Review Board in Gothenburg with approval number: D 374-18.