Gross motor change after inpatient rehabilitation for children with acquired brain injury: A 10-year retrospective review.

AIM: To estimate gross motor change in inpatient school-aged children with subacute acquired brain injury (ABI), identify factors associated with gross motor change, and describe inpatient physiotherapy focus. METHOD: This retrospective chart review involved inpatient children (5-18 years) with subacute ABI who had either two Gross Motor Function Measure (GMFM-88) assessments or one GMFM-88 with another pre/post gross motor outcome measure. Outcome change scores and Goal Attainment Scaling (GAS) T scores were calculated. Regression analyses examined factors predicting gross motor change. GAS goal areas were analysed to determine physiotherapy focus. RESULTS: Of the 546 charts screened, 266 (118 female) met study criteria. The GMFM-88 was generally administered first, followed by other measures. GMFM-88 (n = 202), Community Balance and Mobility Scale (n = 89), and Six-Minute Walk Test (6MWT) (n = 98) mean change scores were 18.03% (SD 19.34), 17.85% (SD 10.77), and 142.3 m (SD 101.8) respectively. The mean GAS T score was 55.06 (SD 11.50). Lower baseline scores and increased time between assessments were most predictive of greater GMFM-88 change (r ≥ 0.40). Twenty-five percent of GAS goals were ambulation-based. INTERPRETATION: Appropriate outcome measure selection is integral to detecting gross motor change in pediatric inpatient ABI rehabilitation. Mean change score estimates can be used to compare standard inpatient rehabilitation with new treatment approaches.

Integrating Transcranial Direct Current Stimulation into an Existing Inpatient Physiotherapy Program to Enhance Motor Learning in an Adolescent with Traumatic Brain Injury: A Case Report.

PURPOSE: Describe how transcranial direct current stimulation (tDCS) was incorporated into an inpatient physiotherapy program for an adolescent with severe traumatic brain injury (TBI), detail the motor learning focus of the physiotherapy sessions, and summarize gross motor progress. METHOD: This case report describes an adolescent who received 20 minutes of anodal tDCS immediately prior to 16 physiotherapy sessions over four weeks. Potential side effects were tracked pre/post tDCS. Gross motor outcomes were measured pre-intervention, post-intervention, and three months post-intervention. Physiotherapy session content was analyzed using therapist documentation and the Motor Learning Strategies Rating Instrument. RESULTS: The youth tolerated tDCS well. The primary side effect was itchiness under the electrodes during tDCS sessions. His mobility progressed from wheelchair use pre- 'tDCS + physiotherapy' to ambulation with a walker post-intervention. His Gross Motor Function Measure score increased 33.1% points pre/post intervention. Session tasks often had several foci (e.g., skill acquisition, strength, and balance) with task focus changing as the youth progressed. Various motor learning strategies were layered within tasks to support performance and learning. CONCLUSIONS: tDCS was successfully integrated into an existing inpatient physiotherapy program for an adolescent with TBI. This protocol provides a structure for implementing, monitoring, and measuring tDCS + physiotherapy in pediatric rehabilitation.

Use of Motor Learning Strategies in Occupational Therapy for Children and Youth with Acquired Brain Injury.

Motor learning strategies (MLS) can be used to promote motor skills acquisition in children and youth with acquired brain injury (ABI). While occupational therapists (OTs) likely use MLS in clinical practice, research has not investigated the extent and variety of their application.Aims: This study explored MLS use by OTs in pediatric ABI and factors influencing their application.Method: Individual video-recorded occupational therapy sessions for a sample of eight children/youth (ages 4-16) with ABI were evaluated via mixed methods approach. The Motor Learning Strategies Rating Instrument (MLSRI-22) quantified the extent of MLS use in each video. Directed content analysis of the videos explored the factors influencing how and when MLS were applied.Results: The most frequently used MLS were promoting problem solving, encouragement, directing attention to the body, permitting errors as part of learning, repetitive practice, and whole practice. Three themes described how and when the OTs used MLS: 1) Getting buy-in, 2) Going with the flow, and 3) Movement and thinking go hand-in-hand.Conclusions: The OTs frequently used MLS with children with ABI, appearing to select MLS based on factors related to the child, task, and environment. These findings are fundamental to future exploration of OT decision-making and evaluation of MLS effectiveness.

Exploring Physiotherapists' Use of Motor Learning Strategies in Gait-Based Interventions for Children with Cerebral Palsy.

Aim: This study investigated physiotherapists' experiences using motor learning strategies (MLS) in gait-based interventions for children with cerebral palsy (CP). The objectives were to explore how child characteristics, physiotherapist decision-making, and treatment approach influenced intentional MLS use.Methods: Semi-structured interviews were conducted with eight physiotherapists who provided gym- and/or Lokomat-based treatment to children with CP. Interviews were analyzed using directed content analysis and a modified constant comparison method.Results: Three themes described their experiences: (1) MLS use is driven by the unique aspects of the child, physiotherapist, and intervention; (2) The use and description of motor learning content varies among physiotherapists; and (3) The Lokomat is "the same but different." Child characteristics were at the forefront of MLS selection in both interventions. The terminology used to describe MLS use varied considerably among therapists. They used similar clinical decision-making in gym- and Lokomat-based interventions.Conclusions: Conscious reflection on the factors affecting MLS use could facilitate related clinical decision-making in physiotherapy interventions for children with CP. Increased awareness of MLS and use of a structured framework for reporting MLS are required to promote intentional MLS use and generate CP-specific evidence-based MLS research.

Reliability of the Motor Learning Strategies Rating Instrument in physiotherapy intervention for children with cerebral palsy.

AIM: To evaluate the reliability of the Motor Learning Strategies Rating Instrument (MLSRI-20) in gait-based, video-recorded physiotherapy interventions for children with cerebral palsy (CP). METHOD: Thirty videos of 18 children with CP, aged 6 to 17 years, participating in either traditional or Lokomat-based physiotherapy interventions were rated using the MLSRI-20. Physiotherapist raters provided general and item-specific feedback after rating each video, which was used when interpreting reliability results. RESULTS: Both interrater and intrarater reliability of the MLSRI-20 total score was good. The interrater reliability intraclass correlation coefficient (ICC) was 0.78 with a 95% confidence interval (CI) of 0.53-0.89 and a coefficient of variation (CV) of 11.8%. The intrarater reliability ICC was 0.89 with a 95% CI of 0.76-0.95 and CV of 7.8%. Rater feedback identified task delineation and interpretation of therapist verbalizations as sources of interrater reliability-related scoring challenges. INTERPRETATION: The MLSRI-20 is a reliable tool for measuring the extent to which a physiotherapist uses motor learning strategies during a video-recorded intervention. These results have clinical and research implications for documenting and analyzing the motor learning content of physiotherapy interventions for children with CP. WHAT THIS PAPER ADDS: The Motor Learning Strategies Rating Instrument (MLSRI-20) is reliable for use by trained physiotherapist raters. Measuring motor learning strategies can identify active 'ingredients' in physiotherapy interventions for children with cerebral palsy. The MLSRI-20 promotes a common language in motor learning.

FIABILIDAD DEL INSTRUMENTO DE CLASIFICACIÓN DE LAS ESTRATEGIAS DE APRENDIZAJE MOTOR EN FISIOTERAPIA: OBJETIVO: Evaluar la fiabilidad del Instrumento de Clasificación de las Estrategias de Aprendizaje Motor (Motor Learning Strategies Rating Instrument, MLSRI-20, siglas en inglés,) en intervenciones fisioterapéuticas basadas en la marcha y grabadas en vídeo para niños con parálisis cerebral (PC). METODOLOGÍA: Se clasificaron 30 vídeos de 18 niños y niñas con PC, de edades comprendidas entre los 6 y 17 años y participando en intervenciones de Fisioterapia tradicionales o basadas en el Lokomat, usando el MLRSI-20. Los evaluadores fisioterapeutas proporcionaron retroalimentación general y específica de los ítems después de clasificar cada vídeo, el cual fue usado al interpretar los resultados de fiabilidad. RESULTADOS: Tanto la fiabilidad inter-observador de la puntuación total del MLSRI-20 como la fiabilidad intra-observador fueron buenas. El coeficiente de correlación intraclase (CCI) de la fiabilidad inter-observador fue de 0,78 con un intervalo de confianza del 95% (IC) de 0,53-0,89 y la variación del coeficiente (VC) del 11,8%. EL CCI de la fiabilidad intra-observador fue 0,89 con un IC95% de 0,76-0-95 y un CV de 7,8%. La retroalimentación del evaluador identificó la delineación de la tarea y la interpretación de las verbalizaciones del terapeuta como fuentes de desafío para puntuar la fiabilidad inter-observador. INTERPRETACIÓN: El MLSRI-20 es una herramienta fiable para medir en qué grado los fisioterapeutas usan estrategias de aprendizaje motor durante una intervención grabada en vídeo. Estos resultados tienen implicaciones clínicas y de investigación para documentar y analizar el contenido de aprendizaje motor en las intervenciones fisioterapéuticas en niños con PC.

CONFIABILIDADE DO INSTRUMENTO DE PONTUAÇÃO DAS ESTRATÉGIAS DE APRENDIZAGEM MOTORA NA INTERVENÇÃO DE FISIOTERAPIA PARA CRIANÇAS COM PARALISIA CEREBRAL: OBJETIVO: Avaliar a confiabilidade do Instrumento de Pontuação das Estratégias de Aprendizagem Motora (Motor Learning Strategies Rating Instrument, MLSRI-20) em intervenções de fisioterapia para crianças com paralisia cerebral (PC) baseadas na marcha e registradas por vídeo. MÉTODO: Trinta videos de 18 crianças com PC, com idades de 6 a 17 anos, participando ou em intervenções de fisioterapia baseada no Lokomat foram pontuadas usando o MLSRI-20. Os examinadores fisioterapeutas forneceram uma avaliação geral e item-específica após pontuar cada vídeo, o que foi usado para interpretar os resultados de confiabilidade. RESULTADOS: Tanto a confiabilidade inter-examinador quanto intra-examinador do MLSRI-20 foi boa. O coeficiente de correlação intraclasse (CCI) da confiabilidade inter-foi 0,78 com intervalo de confiança (IC) a 95% de 0,53-0,89 e coeficiente de variação (CV) de 11,8%. O CII da confiabilidade intra-examinador foi 0,89 com CI a 95% de 0,76-0,95 e CV de 7,8%. A avaliação dos examinadores identificou o delineamento da tarefa e as verbalizações dos terapeutas para interpretação como fontes de desafios na pontuação da confiabilidade inter-examinadores. INTERPRETAÇÃO: O MLSRI-20 é uma ferramenta confiável para mensurar a extensão em que um fisioterapeuta usa estratégias de aprendizagem motora durante uma intervenção gravada em video. Os resultados têm implicações clínicas e científicas para a documentação e análise do conteúdo de aprendizagem motora em crianças com PC.

Optimizing an exercise training program in pediatric brain tumour survivors: Does timing postradiotherapy matter?

Background: While exercise training (ET) programs show positive outcomes in cognition, motor function, and physical fitness in pediatric brain tumor (PBT) survivors, little is known about the optimal timing of intervention. The aim of this work was to explore the feasibility and benefits of ET based on its timing after radiotherapy. Methods: This retrospective analysis (ClinicalTrials.gov, NCT01944761) analyzed data based on the timing of PBT survivors' participation in an ET program relative to their completion of radiotherapy: <2 years (n = 9), 2-5 years (n = 10), and > 5 years (n = 13). We used repeated measures analysis of variance to compare feasibility and efficacy indicators among groups, as well as correlation analysis between ET program timing postradiotherapy and preliminary treatment effects on cognition, motor function and physical fitness outcomes. Results: Two to five years postradiotherapy was the optimal time period in terms of adherence (88.5%), retention (100%), and satisfaction (more fun, more enjoyable and recommend it more to other children). However, the benefits of ET program on memory recognition (r = -0.379, P = .047) and accuracy (r = -0.430, P = .032) decreased with increased time postradiotherapy. Motor function improved in all groups, with greater improvements in bilateral coordination (P = .043) earlier postradiotherapy, and in running (P = .043) later postradiotherapy. The greatest improvement in pro-rated work rate occurred in the < 2-year group (P = .008). Conclusion: Participation in an ET program should be offered as part of routine postradiotherapy care in the first 1-2 years and strongly encouraged in the first 5 years.

Clinicians' perspectives on motor learning strategy selection and application in occupational therapy and speech-language pathology interventions for children with acquired brain injury.

PURPOSE: Explore occupational therapists' (OTs) and speech language pathologists' (SLPs) process of selecting and applying motor learning strategies (MLS) in their interventions for children with acquired brain injury (ABI), and identify similarities and differences between OTs and SLPs in MLS selection and application. METHODS: This qualitative descriptive study involved individual semi-structured interviews with OTs and SLPs from the ABI program at Holland Bloorview Kids Rehabilitation Hospital (Toronto, Canada). Interviews were analyzed using thematic analysis. A modified constant comparison method permitted comparison within and between professions. RESULTS: Four OTs and three SLPs were interviewed. Four themes were developed: aligning MLS application with the child's cognitive ability, using MLS to promote success within a single session, adjusting MLS across treatment sessions, and promoting generalization and transfer of motor skills beyond the therapy session. MLS application was predominately based on child-specific factors with task-specific considerations. OTs and SLPs used similar clinical reasoning processes for selecting and applying MLS. CONCLUSIONS: This study provides a greater understanding of OTs' and SLPs' clinical reasoning process when applying MLS in pediatric ABI interventions. The similarities in MLS selection and application between disciplines suggest that an interprofessional approach to MLS is suitable for pediatric ABI rehabilitation.

Pediatric occupational therapists and speech language pathologists use a similar process for selecting and applying motor learning strategies (MLS) in their interventionsClinicians continually reflect upon and adapt their use of MLS based on each child's performance, progress, and goalsAdopting an interprofessional approach to MLS selection and application, including the use of a common MLS language, has the potential to optimize motor outcomes in pediatric acquired brain injury rehabilitation.

Motor Evoked Potential Amplitude in Motor Behavior-based Transcranial Direct Current Stimulation Studies: A Systematic Review.

Motor evoked potential amplitude (MEPamp) is frequently measured in transcranial direct current stimulation (tDCS) studies that target the primary motor cortex (M1), and a subset of these studies involve motor behavior. This systematic review explored the role of MEPamp as an indicator of neural change in M1-targeted tDCS studies involving motor behavior (i.e., motor practice and/or evaluation of motor performance) in healthy individuals, and examined the association between changes in motor performance and MEPamp. We executed our search strategy across four bibliographic databases. Twenty-two manuscripts met eligibility criteria. While anodal tDCS combined with motor practice frequently increased MEPamp, MEPamp outcomes did not necessarily align with changes in motor performance. Thus, MEPamp may not be the most appropriate indicator of neural change in tDCS studies that aim to improve motor performance.

Reliability of the Revised Motor Learning Strategies Rating Instrument and Its Role in Describing the Motor Learning Strategy Content of Physiotherapy Sessions in Paediatric Acquired Brain Injury.

Purpose: Documenting the use of motor learning strategies (MLS) in physiotherapy is a foundational step in understanding the effectiveness of motor skills-based treatments in paediatric acquired brain injury (ABI). The purpose of this study was to estimate the inter- and intrarater reliability of the revised Motor Learning Strategies Rating Instrument (MLSRI-22) in physiotherapy for children and youth with ABI when administered by trained student physiotherapists. The MLSRI-22 was then used to describe the MLS content of traditional and robotic treadmill training physiotherapy sessions for children with ABI to demonstrate its application. Method: Thirty videos of children with ABI receiving Lokomat or traditional physiotherapy were rated using the MLSRI-22. Inter- and intrarater reliability were estimated using intra-class correlation coefficients (ICCs). Mean MLSRI-22 item scores described the MLS session content. Results: MLSRI-22 total score inter- and intrarater ICCs were 0.81 (95% CI: 0.61, 0.91) and 0.95 (95% CI: 0.90, 0.98), respectively. There were similarities and differences in MLS content between treatment approaches. Conclusions: Trained assessors can reliably administer the MLSRI-22 in physiotherapy for children with ABI. Research using MLSRI-22 scores to explore and systematically compare MLS across treatment approaches may provide insight into their effectiveness and contribute to MLS practice guidelines for children with ABI.

Objectif : il est essentiel de répertorier les stratégies d'apprentissage moteur (SAM) utilisées en physiothérapie pour comprendre l'efficacité des traitements pédiatriques reposant sur les habiletés motrices en cas de lésions cérébrales acquises (LCA). La présente étude visait à évaluer la fiabilité interévaluateur et intraévaluateur de l'instrument d'évaluation révisé des stratégies d'apprentissage moteur (MLSRI­22) en physiothérapie chez les enfants et les adolescents ayant des LCA, lorsqu'il était utilisé par des étudiants en physiothérapie. Le MLSRI­22 a ensuite été utilisé pour décrire le contenu des SAM de séances de formation sur tapis roulant classique et robotique chez des enfants ayant des LCA et ainsi en démontrer l'application. Méthodologie : les chercheurs ont classé 30 vidéos d'enfants ayant des LCA recevant des services Lokomat ou de physiothérapie classique au moyen du MLSRI­22. Ils ont évalué la fiabilité interévaluateur et intraévaluateur à l'aide des coefficients de corrélation intraclasse (CCI). Les scores moyens du MLSRI­22 décrivaient le contenu de la séance de SAM. Résultats : les CCI interévaluateurs et intraévaluateurs du score total du MLSRI­22 s'élevaient à 0,81 (IC à 95 % : 0,61, 0,91) et à 0,95 (IC à 95 % : 0,90, 0,98), respectivement. Il y avait des similarités et des différences dans les démarches thérapeutiques des SAM. Conclusion : des évaluateurs formés peuvent utiliser le MLSRI­22 en toute fiabilité en physiothérapie auprès des enfants ayant des LCA. Les recherches faisant appel aux scores du MLSRI­22 pour explorer et comparer systématiquement les diverses démarches thérapeutiques des SAM peuvent donner un aperçu de leur efficacité et contribuer à la préparation de directives cliniques sur les SAM chez les enfants ayant des LCA.

Integrated analysis of the molecular pathogenesis of FDXR-associated disease.

The mitochondrial flavoprotein ferredoxin reductase (FDXR) is required for biogenesis of iron-sulfur clusters and for steroidogenesis. Iron-sulfur (Fe-S) clusters are ubiquitous cofactors essential to various cellular processes, and an increasing number of disorders are associated with disruptions in the synthesis of Fe-S clusters. Our previous studies have demonstrated that hypomorphic mutations in FDXR cause a novel mitochondriopathy and optic atrophy in humans and mice, attributed in part to reduced function of the electron transport chain (ETC) as well as elevated production of reactive oxygen species (ROS). Inflammation and peripheral neuropathy are also hallmarks of this disease. In this paper, we demonstrate that FDXR mutation leads to significant optic transport defects that are likely to underlie optic atrophy, a major clinical presentation in FDXR patients, as well as a neurodegenerative loss of cells in the central nervous system (CNS). Molecular analysis indicates that FDXR mutation also leads to mitochondrial iron overload and an associated depolarization of the mitochondrial membrane, further supporting the hypothesis that FDXR mutations cause neurodegeneration by affecting FDXR's critical role in iron homeostasis.

Genetic mapping in Diversity Outbred mice identifies a Trpa1 variant influencing late-phase formalin response.

Identification of genetic variants that influence susceptibility to pain is key to identifying molecular mechanisms and targets for effective and safe therapeutic alternatives to opioids. To identify genes and variants associated with persistent pain, we measured late-phase response to formalin injection in 275 male and female Diversity Outbred mice genotyped for over 70,000 single nucleotide polymorphisms. One quantitative trait locus reached genome-wide significance on chromosome 1 with a support interval of 3.1 Mb. This locus, Nociq4 (nociceptive sensitivity quantitative trait locus 4; MGI: 5661503), harbors the well-known pain gene Trpa1 (transient receptor potential cation channel, subfamily A, member 1). Trpa1 is a cation channel known to play an important role in acute and chronic pain in both humans and mice. Analysis of Diversity Outbred founder strain allele effects revealed a significant effect of the CAST/EiJ allele at Trpa1, with CAST/EiJ carrier mice showing an early, but not late, response to formalin relative to carriers of the 7 other inbred founder alleles (A/J, C57BL/6J, 129S1/SvImJ, NOD/ShiLtJ, NZO/HlLtJ, PWK/PhJ, and WSB/EiJ). We characterized possible functional consequences of sequence variants in Trpa1 by assessing channel conductance, TRPA1-TRPV1 interactions, and isoform expression. The phenotypic differences observed in CAST/EiJ relative to C57BL/6J carriers were best explained by Trpa1 isoform expression differences, implicating a splice junction variant as the causal functional variant. This study demonstrates the utility of advanced, high-precision genetic mapping populations in resolving specific molecular mechanisms of variation in pain sensitivity.

Patterns and correlates of tobacco control behavior among american association of pediatric dentistry members: a cross-sectional national study.

BACKGROUND: To determine the tobacco-related knowledge, attitudes, and practice behaviors among US pediatric dentists. METHODS: A survey was conducted in 1998 among a national, random sample of 1500 American Academy of Pediatric Dentistry members. Chi-square tests and logistic regression with odds ratios (ORs) and 95% confidence intervals assessed factors related to pediatric dentists' tobacco control behaviors. RESULTS: Response was 65% for the survey. Only 12% of respondents had prior tobacco prevention/cessation training. Of those untrained, 70% were willing to be trained. Less than two-thirds correctly answered any of four tobacco-related knowledge items. Over one-half agreed pediatric dentists should engage in tobacco control behaviors, but identified patient resistance as a barrier. About 24% of respondents reported always/often asking their adolescent patients about tobacco use; 73% reported always/often advising known tobacco users to quit; and 37% of respondents always/often assisting with stopping tobacco use. Feeling prepared to perform tobacco control behaviors (ORs = 1.9-2.8), a more positive attitude score (4 points) from 11 tobacco-related items (ORs = 1.5-1.8), and a higher statewide tobacco use prevalence significantly predicted performance of tobacco control behaviors. CONCLUSION: Findings suggest thatraining programs on tobacco use and dependence treatment in the pediatric dental setting may be needed to promote tobacco control behaviors for adolescent patients.

Continuous Glucose Monitoring in Female NOD Mice Reveals Daily Rhythms and a Negative Correlation With Body Temperature.

Previous studies with continuous glucose monitoring in mice have been limited to several days or weeks, with the mouse's physical attachment to the equipment affecting behavior and measurements. In the current study, we measured blood glucose and body temperature at 10-second intervals for 12 weeks in a cohort of NOD/ShiLtJ female mice using wireless telemetry. This allowed us to obtain a high-resolution profile of the circadian rhythm of these two parameters and the onset of hyperglycemic development in real time. The most striking observations were the elevated nocturnal concentrations of glucose into the diabetic range days before elevations in diurnal glucose (when glucose concentrations are historically measured) and the strong, negative correlation between elevated blood glucose concentrations and body temperature with a steady decline of the body temperature with diabetes development. Taken together, this technological advancement provides improved resolution in the study of the disease trajectory of diabetes in mouse models, including relevant translatability to the current technologies of continuous glucose monitoring now regularly used in patients.

The effect of broadleaf woodland on aluminium speciation in stream water in an acid-sensitive area in the UK.

Acidification can result in the mobilisation and release of toxic inorganic monomeric aluminium (Al) species from soils into aquatic ecosystems. Although it is well-established that conifer trees enhance acidic atmospheric deposition and exacerbate soil and water acidification, the effect of broad-leaved woodland on soil and water acidification is less clear. This study investigated the effect of broadleaf woodland cover on the acid-base chemistry and Al species present in stream water, and processes controlling these in the acid-sensitive area around Loch Katrine, in the central Highlands, Scotland, UK, where broadleaf woodland expansion is occurring. A nested sampling approach was used to identify 22 stream sampling locations, in sub-catchments of 3.2-61 ha area and 0-45% broadleaf woodland cover. In addition, soils sampled from 68 locations were analysed to assess the influence of: (i) broadleaf woodland cover on soil characteristics and (ii) soil characteristics on stream water chemistry. Stream water pH was negatively correlated with sub-catchment % woodland cover, indicating that woodland cover is enhancing stream water acidification. Concentrations of all stream water Al species (monomeric total, organic and inorganic) were positively correlated with % woodland cover, although not significantly, but were below levels that are toxic to fish. Soil depth, O horizon depth and soil chemistry, particularly of the A horizon, appeared to be the dominant controls on stream water chemistry rather than woodland cover. There were significant differences in soil acid-base chemistry, with significantly lower O horizon pH and A horizon base saturation and higher A horizon exchangeable Al in the wooded catchments compared to the control. This is evidence that the mobile anion effect is already occurring in the study catchments and suggests that stream water acidification arising from broadleaf woodland expansion could occur, especially where tree density is high and acid deposition is predominantly in dry or occult forms.