Effects of conventional versus virtual reality-simulated treadmill exercise on fatigue, cognitive function, and participant satisfaction in post-COVID-19 subjects. A randomized trial.

Background/objective: Post-COVID-19 subjects typically experience symptoms of fatigue, cognitive impairment, and sleep difficulty, which can be relieved by conventional aerobic exercise. Virtual Reality (VR) technology to support conventional exercise has recently gained much attention. Therefore, this study aimed to assess the effects of traditional treadmill exercise compared to virtual reality-simulated treadmill exercise on fatigue, cognitive function, sleep quality, and participant satisfaction with the exercise program in post-COVID-19 subjects. Methods: This single-centered, randomized, parallel-group intervention study was conducted between December 2021 and March 2022. Sixteen of twenty post-COVID-19 subjects completed this study (n1 = 8, n2 = 8). Inclusion criteria were persistent dyspnea/fatigue, mild cognitive problems, and age from 30-60 years. Exclusion criteria were previous severe COVID-19 infection and ICU admission, concomitant respiratory or cardiovascular disease, and musculoskeletal or neurological disease. Eligible subjects were assigned randomly to two groups: a non-VR group that received traditional treadmill aerobic exercise only and a VR group that received treadmill exercise with non-immersive VR. Both groups received moderate-intensity exercise on a treadmill at [50-60 % (peak HR－resting HR) + resting HR] for 30-45 min, three times per week, and for four weeks. The outcome measures were the Chalder Fatigue Scale, Montreal Cognitive Assessment (MoCA) questionnaire, Pittsburgh Sleep Quality Index (PSQI), and participant satisfaction with the exercise program rated on a 5-point Likert scale. Results: Both groups showed significant improvements in the Chalder Fatigue Scale, the MoCA questionnaire, and the PSQI scores after training compared to baseline (p < 0.05), without significant differences between them (p > 0.05). However, participant satisfaction with the exercise program was significantly higher in the VR group than in the non-VR group (p = 0.037). Conclusion: A moderate-intensity 4-week treadmill exercise program with and without non-immersive VR may improve fatigue, cognitive function, and sleep quality to the same extent in COVID-19 survivors. However, participant satisfaction with the exercise program could be greater after conventional treadmill training assisted by non-immersive VR than after conventional treadmill training alone in this cohort. Trial registration: Pan African Clinical Trials Registry, PACTR202311561948428, retrospectively registered.

Effect of Buerger-Allen exercise on wound healing in patients with diabetic foot ulcers: a randomised controlled trial.

OBJECTIVE: A diabetic foot ulcer (DFU) is a complication of type 2 diabetes that is difficult to treat. Buerger-Allen exercise has shown effectiveness in improving foot circulation and neuropathy in several studies; however, to the best of our knowledge, no randomised controlled study has investigated its effectiveness for DFU healing. Therefore, this study aimed to assess the effects of Buerger-Allen exercise on the healing of DFUs in patients with type 2 diabetes. METHOD: This is a parallel-group randomised controlled trial (RCT). Of 50 patients with neuropathic DFUs, 41 completed the study. They were assigned randomly to a study group (n=21) and a control group (n=20). Patients in the study group received the standard medical treatment and semi-supervised Buerger-Allen exercise for three sessions per week for four weeks, while patients in the control group only received the standard medical treatment. The outcome measures were: ankle-brachial pressure index (ABPI); ulcer size; ulcer depth; SINBAD score; and ulcer risk for poor outcomes (based on the SINBAD score). RESULTS: The study group's mean age was 49.48±6.45 years and the control group's mean age was 49.15±5.85. The study group's ABPI increased significantly compared to the baseline (1.17±0.04 versus 1.11±0.05, respectively; p<0.001) and the control group (1.17±0.04 versus 1.14±0.05, respectively; p=0.04) post-intervention. Ulcer size also reduced significantly in the study group compared to the baseline (2.63±2.0 versus 7.48±5.55cm2, respectively; p<0.001) and the control group (2.63±2.0 versus 6.43±4.45cm2, respectively; p<0.001) post-intervention. Ulcer depth decreased significantly in the study group compared to the baseline (1.71±1.05 versus 4.19±1.74mm, respectively; p<0.001) and the control group (1.71±1.05 versus 2.80±1.57mm, respectively; p=0.01) post-intervention. Furthermore, the SINBAD score in the study group decreased significantly compared to the baseline (1.38±0.86 versus 2.14±1.06, respectively; p<0.001) and the control group (1.38±0.86 versus 2.0±0.79, respectively; p=0.02) post-intervention. Moreover, the ulcer risk for poor outcomes, based on the SINBAD score, reduced significantly only in the study group, compared to the baseline (p=0.041). The control group showed non-significant changes compared to the baseline in all outcome measures (p>0.05). CONCLUSION: From the findings of this RCT, Buerger-Allen exercise, in combination with standard wound care, may help accelerate the healing of neuropathic DFUs in patients with type 2 diabetes, and could be suggested as part of the management plan for such conditions as an easy-to-perform offloading exercise intervention.

Effect of Adding Early Bedside Cycling to Inpatient Cardiac Rehabilitation on Physical Function and Length of Stay After Heart Valve Surgery: A Randomized Controlled Trial.

OBJECTIVE: To assess whether adding bedside cycling to inpatient cardiac rehabilitation (CR) early after heart valve surgery could lead to better physical function and shorter length of hospital stays. DESIGN: This is a single-centered, randomized, controlled, parallel-group intervention study. SETTINGS: This study was conducted at the National Heart Institute from December 2022 to June 2023. PARTICIPANTS: Thirty-one patients following heart valve surgery completed this study after being randomized into 2 groups: an intervention group (n1=16) and an active control group (n2=15). Eligibility criteria were heart valve surgery with median sternotomy, clinical stability, and age from 20 to 40 years. INTERVENTIONS: The intervention group received early bedside cycling for the lower limbs, using a mini bike, in addition to an inpatient CR program, and the control group received the inpatient CR program alone. MAIN OUTCOME MEASURE: The primary outcome was the physical functional capacity assessed by the 6-minute walk distance (6MWD). The secondary outcomes were the Barthel Index (BI), the forced vital capacity (FVC), the length of intensive care unit (ICU) stay, the total length of hospital stay, and the physical component summary (PCS) of the 12-item Short Form (SF-12) Health Survey. RESULTS: Compared with the control group, the intervention group showed significantly greater 6MWD (P<.001), BI score (P<.001), and FVC (P=.006) at hospital discharge, and shorter ICU stay (P=.002) and total hospital stay (P=.015). At 1-month follow-up, the intervention group showed a non-significantly higher PCS mean score than the control group (P=.057). CONCLUSION: Adding early bedside cycling to a usual inpatient CR program after heart valve surgery could induce significantly greater short-term physical functional capacity as assessed by the 6MWD, better activities of daily living as evaluated by the BI, higher pulmonary function as measured by the FVC, and shorter lengths of ICU and total hospital stays than the usual inpatient CR program alone.

Effects of low-versus high-volume high-intensity interval training on glycemic control and quality of life in obese women with type 2 diabetes. A randomized controlled trial.

Background/objective: Comparison between different training volumes of high-intensity interval training (HIIT) is understudied in type 2 diabetes. This study aimed to compare the effects of low- and high-volume HIIT on glycemic control, blood lipids, blood pressure, anthropometric adiposity measures, cardiorespiratory fitness, and health-related quality of life (HRQoL) in women with type 2 diabetes. Methods: Seventy-two obese women with type 2 diabetes aged 36-55 were randomly assigned to a low-volume HIIT group (i.e., 2 × 4-min high-intensity treadmill exercise at 85%-90% of peak heart rate, with a 3-min active recovery interval in between), a high-volume HIIT group (i.e., 4 × 4-min high-intensity treadmill exercise at 85%-90% of peak heart rate, with three 3-min active recovery intervals in between), and a non-exercising control group. Patients in HIIT groups exercised three days a week for 12 weeks. All patients received oral hypoglycemic medications with no calorie restrictions. The outcome measures were glycosylated hemoglobin (HbA1c), fasting blood glucose (FBG), 2-hour postprandial blood glucose (2-hr PPBG), total cholesterol (TC), triglyceride (TG), low-density lipoprotein (LDL), high-density lipoprotein (HDL), systolic blood pressure (SBP), diastolic blood pressure (DBP), body mass index (BMI), waist circumference (WC), waist-to-hip ratio, time to maximal exhaustion determined from a maximal treadmill exercise test (i.e., a measure of cardiorespiratory fitness), and HRQoL assessed by the 12-item Short Form (SF-12) Health Survey. Results: The low- and high-volume HIIT groups showed significant improvements in all outcome measures compared to the baseline and the non-exercising group (P < 0.05), except for DBP in the low-volume HIIT group (p > 0.05). Also, both low- and high-volume HIIT groups showed similar improvements in TC, HDL, SBP, DBP, BMI, WC, waist-to-hip ratio, and the SF-12 scores, with no significant between-groups difference (p > 0.05). The high-volume HIIT group, however, showed more significant improvements in HbA1c, FBG, 2-hr PPBG, TG, LDL, and treadmill time to maximal exhaustion than the low-volume HIIT group (p < 0.05). The non-exercising group showed non-significant changes in all outcome measures (p > 0.05). Conclusion: Low-volume HIIT could be equally effective as high-volume HIIT for improving TC, HDL, blood pressure, anthropometric adiposity measures, and HRQoL in obese women with type 2 diabetes. Nevertheless, high-volume HIIT could have a greater impact on glycemic control, TG, LDL, and cardiorespiratory fitness in these patients. Trial registration: ClinicalTrials.gov, NCT05110404.

Effects of aerobic, resistance, and combined training on thyroid function and quality of life in hypothyroidism. A randomized controlled trial.

PURPOSE: This study aimed to compare the effects of aerobic, resistance, and combined exercises on thyroid function, lipid profile, exercise capacity, and quality of life (QoL) in hypothyroid women. METHODS: Sixty women aged 35 to 45 with clinical hypothyroidism were randomized to four equal groups: aerobic training (AT), resistance training (RT), combined AT/RT, and control groups. All exercises were performed at low to moderate intensity, three days per week, and for 12 weeks. Patients in all groups were on levothyroxine therapy. Outcome measures were free thyroxin (T4), thyroid stimulating hormone (TSH), lipid profile, estimated maximal oxygen consumption (VO2 max) and QoL assessed by the 12-item Short Form (SF-12) Health Survey. RESULTS: All exercise groups showed significant improvements in all outcome measures compared to the baseline and the controls (p < 0.05). The combined AT/RT group showed more significant improvements in TSH and the mental component summary score of the SF-12 compared to the AT and RT groups (p < 0.05). The AT group showed the most significant improvement in estimated VO2 max, followed by the combined AT/RT and then the RT group. Non-significant differences were found between exercise groups in T4, blood lipids, and the physical component summary score of the SF-12 (p > 0.05). CONCLUSION: In women with hypothyroidism on levothyroxine treatment, all AT, RT, and combined AT/RT could equally improve T4 levels, lipid profile, and physical health-related QoL. However, the combined AT/RT could induce the greatest improvements in TSH and mental health-related QoL, while the AT could have the greatest impact on exercise capacity in these patients. TRIAL REGISTRATION: Pan African Clinical Trial Registry (PACTR), retrospective, PACTR202305810673587.

Effects of early mobilisation program on functional capacity, daily living activities, and N-terminal prohormone brain natriuretic peptide in patients hospitalised for acute heart failure. A randomised controlled trial.

Background: Patients hospitalised for acute decompensated heart failure (ADHF) show reduced functional capacity, limited activities of daily living (ADL), and elevated N-terminal prohormone of brain natriuretic peptide (NT-proBNP). The management of these patients focuses mainly on medical therapy with little consideration for in-patient cardiac rehabilitation. There has been a growing interest in evaluating the efficacy of early mobilisation, as the core for in-hospital rehabilitation, in ADHF patients in the last decade; however, the randomised trials on this topic are few. Objective: This randomised-controlled study, therefore, aimed to further test the hypothesis that early supervised mobilisation would have beneficial effects on functional capacity, ADL, and NT-proBNP in stabilised patients following ADHF. Methods: This is a single-centered, randomised-controlled, parallel-group trial in which 30 patients hospitalised for ADHF were randomly assigned to two groups; the study group (age=55.4±5.46 years, n1=15) and the control group (age=55.73±5.61 years, n2=15). Inclusion criteria were ADHF on top of chronic heart failure independent of etiology or ejection fraction, clinical/hemodynamic stability, age from 40 to 60 years old, and both genders. Exclusion criteria were cardiogenic shock, acute coronary ischemia, or significant arrhythmia. Both groups received the usual medical care, but only the study group received an early structured mobilisation protocol within 3 days of hospital admission till discharge. The outcome measures were the 6-min walk distance (6-MWD) and the rating of perceived exertion (RPE) determined from the 6-min walk test at discharge, the Barthel index (BI), NT-proBNP, and the length of hospital stays (LOS). Results: The study group showed significantly greater improvements compared to the controls in the 6-MWD (252.28±92.32 versus 106.35±56.36 m, P<0.001), the RPE (12.53±0.91 versus 15.4±1.63, P<0.001), and the LOS (10.42±4.23 versus 16.85±6.87 days, p=0.009) at discharge. Also, the study group showed significant improvements in the BI compared to baseline [100 (100-100) versus 41.87 (35-55), p=0.009] and the controls [100 (100-100) versus 92.5(85-95), p=0.006]. The mean value of NT-proBNP showed a significant reduction only compared to baseline (786.28±269.5 versus 1069.03±528.87 pg/mL, p=0.04) following the intervention. The absolute mean change (Δ) of NT-proBNP showed an observed difference between groups in favor of the study group (i.e., Δ=↓282.75±494.13 pg/mL in the study group versus ↓26.42±222.21 pg/mL in the control group, p=0.077). Conclusion: Early structured mobilisation under the supervision of a physiotherapist could be strongly suggested in combination with the usual medical care to help improve the functional capacity and daily living activities, reduce NT-proBNP levels, and shorten the hospital stay in stabilised patients following ADHF. Trial registration number: PACTR202202476383975.

Effect of diaphragm manual release versus conventional breathing exercises and prone positioning on physical functional performance in women with COVID-19: A randomized trial.

INTRODUCTION: Manual therapy has recently gained much interest in managing COVID-19 patients. This study aimed to mainly compare the effect of diaphragm manual release to the effect of conventional breathing exercises and prone positioning on physical functional performance in women with COVID-19. METHODS: Forty COVID-19 women patients completed this study. They were randomly assigned to two groups. Group A received diaphragm manual release, and group B received conventional breathing exercises and prone positioning. Both groups received pharmacological treatment. Inclusion criteria were moderate COVID-19 illness, women patients, and ages from 35 to 45 years. The outcome measures were 6-min walk distance (6MWD), chest expansion, Barthel index (BI), oxygen saturation, fatigue Assessment Scale (FAS), and Medical Research Council (MRC) dyspnea scale. RESULTS: Both groups showed significant improvements in all outcome measures compared to the baseline (p < 0.001). Compared to group B, group A showed more significant improvements in the 6MWD (MD, 22.75 m; 95% CI, 15.21 to 30.29; p < 0.001), chest expansion (MD, 0.80 cm; 95% CI, 0.46 to 1.14; p < 0.001), BI (MD, 9.50; 95% CI, 5.69 to 13.31; p < 0.001), the O2 saturation (MD, 1.3%; 95% CI, 0.71 to 1.89; p < 0.001), the FAS (MD, -4.70; 95% CI, -6.69 to -2.71; p < 0.001), and dyspnea severity assessed by the MRC dyspnea scale (p = 0.013) post-intervention. CONCLUSION: Combined with pharmacological treatment, diaphragm manual release could be superior to conventional breathing exercises and prone positioning in improving physical functional performance, chest expansion, daily living activities, O2 saturation, and measures of fatigue and dyspnea in middle-aged women with moderate COVID-19 illness. TRIAL REGISTRATION: Pan African Clinical Trial Registry (PACTR), retrospective, PACTR202302877569441.

Effect of adding high-intensity interval training to diet and carboxytherapy on metabolic cardiovascular risk factors in women with metabolic syndrome.

Introduction: Metabolic syndrome has traditionally been associated with cardiovascular diseases and has recently been linked to increased susceptibility to COVID-19 infection, thus highlighting the need for multimodal interventions to optimize management of this condition. Aim: To assess the effects of high-intensity interval training (HIIT) alongside a low-fat diet and carboxytherapy on metabolic syndrome features. Material and methods: Sixty women (50-60 years old) diagnosed with metabolic syndrome were assigned to a 4-week intervention of either HIIT in combination with a low-fat diet and carboxytherapy (experimental group: n1 = 30, age = 54.17 ±2.82 years, body mass index (BMI) = 32.10 ±0.91), or a low-fat diet and carboxytherapy only (active control group: n2 = 30, age = 54.10 ±2.64 years, BMI = 32.12 ±1.19). Exclusion criteria were uncontrolled hypertension, diabetes mellitus, coronary artery disease, smoking, contraindications to carboxytherapy, and contraindications to exercise testing/training. Outcome measures were waist circumference (WC), BMI, serum triglycerides (TG), systolic blood pressure (SBP), diastolic blood pressure (DBP), high-density lipoproteins (HDL), and fasting blood glucose (FBG). Results: Both groups showed significant improvements in all outcome measures compared to baseline values (p < 0.05). The experimental group showed significantly greater improvements in mean values of WC, BMI, TG, SBP, DBP, and FBG (p < 0.05), as well as a tendency for a significant difference in HDL (p = 0.075) compared to the control group. Conclusions: The addition of HIIT to a low-fat diet and carboxytherapy could lead to greater improvements in metabolic cardiovascular risk factors in women with metabolic syndrome than a low-fat diet and carboxytherapy alone. This could suggest a good rationale for the inclusion of HIIT in the multimodal interventions rendered to women with metabolic syndrome.

Laser acupuncture for claudication symptoms in peripheral artery disease - Does it work? A randomized trial.

Background: Peripheral artery disease (PAD) receives little attention despite its clinical consequences. Intermittent claudication is the most disturbing symptom of the disease resulting in marked limitations to functional walking performance. Treadmill walking exercise is the first-line non-pharmacological treatment in PAD; however, older patients may be unable to exercise because of the functional disability of the disease itself or deconditioning. Objective: In an attempt to seek an alternative intervention, this study aimed to assess the effect of laser acupuncture on patient-reported claudication symptoms and walk performance in PAD. Methods: Thirty male patients with PAD were assigned randomly to a control group ( n 1 = 15 , 64 . 5 ± 3 . 5 years old, 25 . 9 ± 2 . 6 kg/m2) or a study group ( n 2 = 15 , 65 . 6 ± 3 . 3 years old, 25 . 44 ± 3 . 1 kg/m2). Inclusion criteria were mild-to-moderate PAD, Fontaine stage II, unilateral or bilateral claudications, and older men. Exclusion criteria were asymptomatic PAD, resting pain, severe or critical limb ischemia, ischemic ulcers, and patients contraindicated for laser therapy. Both groups received pharmacological treatment, but only the study group received gallium aluminum arsenide (GaAlAs) laser therapy at nine acupuncture points, namely, Liver 2 (LV2), Stomach 41 (ST41), Urinary bladder 40 (UB40), UB60, UB61, Gall bladder 30 (GB30), GB34, GB38, and GB40 for 2 days/week and five consecutive weeks. A pen-type laser device was used at a wavelength of 654 . 7 ± 2 nm, with a power output of 41 ± 3 . 65 mW, a spot size of 0.08 cm2, and an energy density of 2 J/cm2, for 60 s/point. The Edinburgh Claudication Questionnaire (ECQ) and the 6-min walk distance (6-MWD) were the endpoints of the study. The McNemar-Bowker Test and Generalized Estimating Equations Ordinal Logistic Regression Model were used for the within- and between-group statistical analyses of the categorical data of ECQ, respectively; and a mixed model MANOVA was used for the within- and between-group analyses of the 6-MWD data. Results: There was a significant improvement in patients' response to ECQ only in the study group compared to the baseline ( p = 0 . 002 ) and the controls ( p < 0 . 001 ) after the intervention. The 6-MWD increased significantly in the study group compared to the baseline ( 318 ± 77 m versus 214 ± 60 m, p < 0 . 001 ). Conclusion: The GaAlAs laser acupuncture applied at selected acupoints may be a promising intervention complementary to drug therapy that could help relieve claudication symptoms and improve physical functional performance in older men with PAD (Fontaine stage II). Trials were conducted under the Trial Registration No. PACTR201912698539774.

Effects of Addition of Inspiratory Muscle Training to Exercise-Based Cardiac Rehabilitation on Inspiratory Muscle Strength, Peak Oxygen Consumption, and Selected Hemodynamics in Chronic Heart Failure.

Background: Evidence supports the clinical benefits of isolated inspiratory muscle training (IMT) in patients with chronic heart failure (CHF); however, the rationale of IMT in combination with exercise training in cardiac rehabilitation settings for CHF has yet to be confirmed. Objective: This study aimed to assess the effect of the addition of IMT in combination with aerobic/resistance training (AT/RT) on maximal inspiratory pressure (PImax), peak oxygen consumption (VO2peak), selected hemodynamic variables, and health-related quality of life (HRQoL) compared to sham-IMT combined with AT/RT in patients with CHF. Methods: Twenty-five male patients with CHF completed a 6-month cardiac rehabilitation program of either a sham-IMT/AT/RT program (control group, 51.84 ± 4.56 years old, n1 = 13), or a real-IMT/AT/RT program (study group, 51.75 ± 4.73 years old, n2 = 12). Inclusion criteria were ischemic heart failure, New York Heart Association (NYHA) class II-III, and reduced ejection fraction. Outcome measures were PImax, VO2peak, resting heart rate (RHR), heart rate (HR) reserve, rate pressure product (RPP), left-ventricular ejection fraction, and Minnesota Living with Heart Failure Questionnaire (MLwHFQ). Absolute mean changes from baseline (Δ) in the outcome measures were statistically analyzed as independent outcomes. Results: ΔPImax, ΔRHR, ΔHR reserve, and ΔMLwHFQ total score were significantly greater in the study group than in the control group (p < 0.05). In addition, ΔRPP showed an observed difference in favor of the study group with a tendency towards statistical significance (p = 0.07). Conclusions: IMT could be a successful complementary intervention to exercise-based cardiac rehabilitation programs comprising AT/RT, yielding greater improvements in PImax, RHR, HR reserve, and HRQoL in male patients with ischemic heart failure (NYHA class II-III).

Moderate-intensity continuous training: is it as good as high-intensity interval training for glycemic control in type 2 diabetes?

In Egypt, type 2 diabetes is higher in females than in males. Moderate-intensity continuous training (MICT) has been the most widely used exercise form in type 2 diabetes. This study aims to compare the classical MICT to the newly popular high intensity interval training (HIIT) with regard to changes in glycosylated hemoglobin (HbA1c) and estimated average glucose (eAG) in female type 2 diabetics. Twenty-six female patients with type 2 diabetes were assigned into three groups: a control group (n=9), a MICT group (n=9), and a HIIT group (n=8). Patients in both groups exercised on treadmill three days/week for 8 weeks. Patients in MICT exercised continuously for about 40 min at 65%-75% of peak heart rate (HRpeak). Patients in HIIT exercised for 4×4 min at 85%-90% of HRpeak with 3-min recovery in between at 65%-75% of HRpeak. Results showed that HbA1c was reduced significantly from 8.2% (7.45%-8.65%) to 6.9% (6.6%-7.15%) in MICT and from 8.23% (7.94%-8.85%) to 6.25% (6.1%-6.89%) in HIIT after interventions. Likewise, eAG was significantly reduced from 188.64 mg/dL (167.11-201.55 mg/dL) to 151.33 mg/dL (142.72-158.50 mg/dL) in MICT and from 189.64 mg/dL (181.18-207.29 mg/dL) to 136.69 mg/dL (128.37-151.04 mg/dL) in HIIT. No significant difference was found between HIIT and MICT in the measured variables. It is concluded that the less physically demanding MICT is as good as HIIT for normalizing hyperglycemia in type 2 diabetic females. Therefore, recent interests surrounding HIIT should not overemphasize it compared to the traditional MICT for improving glycemic outcomes.

Essentials of Physiotherapy after Thoracic Surgery: What Physiotherapists Need to Know. A Narrative Review.

Physiotherapy has recently become an essential part of enhanced recovery protocols after thoracic surgery. The evidence-based practice of physiotherapy is essential for the effective management of postoperative patients. Unfortunately, only a small body of literature has discussed the rationale of the physiotherapy interventions that are routinely implemented following thoracic surgery. Nonetheless, we can integrate the available knowledge into our practice until new evidence emerges. Therefore, in this review, the principles of physiotherapy after thoracic surgery are presented, along with a detailed description of physiotherapy interventions, with the goals of enhancing the knowledge and practical skills of physiotherapists in postoperative care units and helping them to re-evaluate and justify their traditional practices.