Dual-Tasking Effects on Gait and Turning Performance of Stroke Survivors with Diabetic Peripheral Neuropathy.

BACKGROUND: Stroke survivors depend on the unaffected leg during walking and standing. The presence of diabetic peripheral neuropathy (DPN) affecting both legs may further affect the postural balance and gait instability and increase the risk for falls in such patients. Thus, this study was conducted to investigate the effect of dual taskings on the gait and turning performance of stroke survivors with DPN. METHODS: Forty stroke survivors were recruited (20 with DPN and 20 without DPN) in this cross-sectional study design. Instrumented timed up and go (iTUG) tests were conducted in three different tasking conditions (single task, dual motor and dual cognitive). APDM® Mobility Lab system was used to capture the gait parameters during the iTUG tests. A two-way mixed analysis of variance was used to determine the main effects of gait performance on three taskings during the iTUG test. RESULTS: Spatiotemporal gait parameters and turning performance (turning time and turning step times) were more affected by the tasking conditions in stroke survivors with DPN compared to those without DPN (P < 0.05). CONCLUSION: Stroke survivors with DPN had difficulty walking while turning and performing a secondary task simultaneously.

Regression equations to estimate the 2-min walk distance in an adult Asian population aged 40-75 years.

BACKGROUND AND OBJECTIVE: There is increased use of the 2-min walk test (2MWT) to assess functional exercise capacity. However, the distance achieved during this test may be difficult to interpret in the absence of reference values from a local population. Regression equations to estimate the 2-min walk distance (2MWD) only exist for American and Brazilian populations. The objective of this study was to develop regression equations to estimate the 2MWD in Malaysian adults who were free from major health problems. METHODS: Eighty-seven adults (43 males; mean ± SD age: 57.1 ± 9.6 years) performed two 2MWT using a standardized protocol. Heart rate (HR) was recorded every 30 s during the test. Stepwise multiple regression analysis was performed using age, gender, height, weight and change in HR (ΔHR) as independent variables, and better of the two 2MWD as the dependent variable. A second regression equation, without ΔHR, was planned if ΔHR was retained as one of the predictors of the 2MWD in the first equation. RESULTS: The better of the two 2MWD was 200 ± 34 m. Males walked 33 ± 6 m further than females (P < 0.001). The two regression equations were 196 - 1.1 × age, years + 1.0 × ΔHR, bpm + 31.2 × gender (R2 = 0.73) and 279 - 1.7 × age, years + 35.9 × gender (R2 = 0.47) with females = 0 and males = 1. CONCLUSION: The equations derived in this study may facilitate the interpretation of the 2MWD in clinical populations in Malaysia, as well as in countries with similar cultural backgrounds to Malaysia.

Effects of a Behavioral and Exercise Program on Depression and Quality of Life in Community-Dwelling Older Adults: A Controlled, Quasi-Experimental Study.

Sedentary behavior and low participation in exercise among older adults can lead to depression and low quality of life (QOL). The current study investigated the effects of behavioral and exercise programs on depression severity and QOL among Malaysian community-dwelling older adults. A controlled, quasi-experimental, pre-posttest design was used. A total of 63 participants were divided into three groups: (a) exercise and behavior group (EBG), (b) exercise only group (EG), and (c) control group (CG). Results showed a significant difference in depression among groups (F(2,58) = 33.49, p < 0.01, η(2) = 0.54; mean, EBG < EG < CG) and in physical (F(2,58) = 5.33, p < 0.01, η(2)= 0.16; mean, EBG > EG > CG) and mental (F(2,58) = 4.08, p < 0.01, η(2) = 0.12; mean, EBG > CG > EG) scores of QOL. A combination of behavioral and exercise programs has superior effects on depression and QOL of older adults. [Journal of Gerontological Nursing, 42(2), 45-54.].

Range of motion, muscle length, and balance performance in older adults with normal, pronated, and supinated feet.

[Purpose] To compare the lower limb joint range of motion and muscle length between different types of foot posture, and determine the correlation of range of motion and muscle length with balance performance. [Subjects and Methods] Ninety individuals (age, 65.2±4.6 years) were assessed using the Foot Posture Index to determine their type of foot (Normal [0 to +5], pronated [+6 to +9], and supinated [-1 to -4]; n=30 per group). The range of motion (goniometer), muscle length (goniometer and tape measure), and balance performance (functional reach test and four square step test) were measured for each participant. Data were analyzed using the Kruskal-Wallis test and Spearman's rank-order correlation. [Results] No significant differences were found in range of motion, muscle length, and balance performance among different types of foot posture, except for right and left ankle dorsiflexion range of motion. Balance performance was significantly correlated with selected muscle length and range of motion, especially in the supinated foot. [Conclusion] Range of motion and muscle length of the lower limb may be associated with balance performance in older adults with foot deformities. These findings may guide physiotherapists in choosing intervention based on specific assessments for older adults with foot deformity.

Preliminary study of the patterns and physical risk factors of work-related musculoskeletal disorders among academicians in a higher learning institute.

BACKGROUND: Research has been conducted on the prevalence and physical risk factors of work-related musculoskeletal disorders (WMSDs) among occupations such as agriculture workers, office workers, school teachers, and health care professionals. However, a paucity of research exists on the patterns and physical risk factors of WMSDs among the academicians in a higher learning institution. This study was conducted to determine the patterns and physical risk factors of WMSDs among the academicians. METHODS: A cross-sectional study was conducted among 228 subjects with a mean age of participants of 32.3 ± 7.8 for a period of 1 year from December 2011 until December 2012. An extended neordic musculoskeletal questionnaire (NMQ-E) was used to assess the patterns of work-related musculoskeletal disorders. The short version of the Dutch musculoskeletal questionnaire (DMQ) was used to determine the physical risk factors of WMSDs among the academicians. Descriptive statistics and Pearson Chi square test were used for data analysis. RESULTS: The 1-year pattern of WMSDs among the academicians were neck pain (44.7 %), followed by shoulder pain (40.4 %), upper and lower back pain (33.3 %), and the least common region was elbow pain (3.5 %). Among 20 common physical activities in DMQ, 15 physical activities performed by the academicians in their workplace were considered as a physical risk factors for neck, shoulder, and back pain at p < 0.05. CONCLUSION: The preliminary study demonstrated that neck pain, shoulder pain, and back pain were the most common WMSDs among the academicians in a higher learning institution.

The impact of a submaximal level of exercise on balance performance in older persons.

OBJECTIVE: The purpose of this study was to determine the impact of a submaximal level of exercise on balance performance under a variety of conditions. MATERIAL AND METHOD: Thirteen community-dwelling older persons with intact foot sensation (age = 66.69 ± 8.17 years, BMI = 24.65 ± 4.08 kg/m(2), female, n = 6) volunteered to participate. Subjects' balance performances were measured using the Modified Clinical Test of Sensory Integration of Balance (mCTSIB) at baseline and after test, under four conditions of stance: (1) eyes-opened firm-surface (EOF), (2) eyes-closed firm-surface (ECF), (3) eyes-opened soft-surface (EOS), and (4) eyes-closed soft-surface (ECS). The 6-minute walk test (6MWT) protocol was used to induce the submaximal level of exercise. Data was analyzed using the Wilcoxon Signed-Rank Test. RESULTS: Balance changes during EOF (z = 0.00, P = 1.00) and ECF (z = -1.342, P = 0.180) were not significant. However, balance changes during EOS (z = -2.314, P = 0.021) and ECS (z = -3.089, P = 0.02) were significantly dropped after the 6MWT. CONCLUSION: A submaximal level of exercise may influence sensory integration that in turn affects balance performance, particularly on an unstable surface. Rehabilitation should focus on designing intervention that may improve sensory integration among older individuals with balance deterioration in order to encourage functional activities.

Comparison of gait parameters across three attentional loading conditions during timed up and go test in stroke survivors.

BACKGROUND: Little is known about the effects of attentional loading on performance of turning during walking in individuals with stroke. OBJECTIVE: The authors used a cross-sectional experimental design to compare gait parameters in stroke survivors across 3 attentional loading conditions (single, dual-motor, and dual-cognitive conditions) during a Timed Up and Go (TUG) test. METHODS: Data were collected from 20 stroke survivors (12 males, 8 females; mean age, 60.5 ± 10.6 years). We compared the number of steps and time measured during the TUG test under 3 attentional loading conditions and 2 turning directions (nonparetic and paretic sides). We further divided the TUG test into straight walking and turning phases. RESULTS: The number of steps and the time taken during TUG test increased significantly from single- to dual-task conditions (dual motor and dual cognitive). However, there were no significant differences in gait parameters between turning toward the nonparetic and paretic sides. CONCLUSIONS: These findings suggested that gait performance was compromised during dual-task conditions for individuals with stroke. Attentional loading may be incorporated into routine gait assessment and rehabilitation to ensure a successful recovery.

Effects of patient education on the quality of life of patients with type 2 diabetes mellitus: A scoping review.

Introduction: Patient education is an integral component of diabetes mellitus care. The emergence of different methods and characteristics of patient education has led to varying outcomes of quality of life (QoL). Herein, we systematically searched for published studies reporting patient education and its methods and characteristics for improving the QoL of patients with type 2 diabetes mellitus (T2DM). Method: In this scoping review, eligible studies from six databases (PubMed, Scopus, Cochrane Library, Springer Link, Science Direct and Google Scholar) were identified. The keywords used in the search strategies were as follows: health education, health promotion, patient education, diabetes care, QoL, diabetes mellitus and type 2 diabetes mellitus. Two reviewers independently screened all references and full-text articles retrieved to identify articles eligible for inclusion. Results: A total of 203 articles were identified in the initial search. Of them, 166 were excluded after screening the titles and abstracts. Further full-text screening led to the subsequent removal of 22 articles, leaving 15 articles eligible for data extraction. Conclusion: There is a broad array of methods of patient education for improving the QoL of patients with T2DM. Self-management education with supplementary supervision and monitoring effectively improves QoL. Future studies must emphasise the application of holistic education covering psychological distress, diet plan, and physical health.

Effects of Paraplegia Fitness Integrated Training on Physical Function and Exercise Self-Efficacy and Adherence Among Individuals With Spinal Cord Injury.

OBJECTIVE: To determine the effects of the Paraplegia Fitness Integrated Training (PARAFiT) program, which is an integrated graded physical exercise and health education program for individuals with spinal cord injury (SCI). METHODS: This nonrandomized single-blind study included 44 participants, who were assigned to either an intervention (PARAFiT) group or an active control (conventional physiotherapy) group. The intervention group underwent the PARAFiT program (8 weeks), which consisted of circuit-based interval training, progressive upper limb resistance training, and health education sessions. During the unsupervised period, the intervention group continuously underwent health education program once a month for 2 months (8 weeks). Repeated-measures analysis of variance was used for the analysis. RESULTS: The intervention group presented with a higher level of physical activity than did the control group; however, the difference was not significant (p=0.36). Additionally, the intervention group presented with better exercise self-efficacy and cardiorespiratory fitness and stronger bilateral shoulder muscle and handgrip than did the control group (all p<0.05). Exercise adherence was higher in the intervention group than in the control group during both the supervised (80% vs. 75%) and unsupervised (40% vs. 20%) periods. CONCLUSION: The PARAFiT program enhanced the level of physical activity, exercise self-efficacy, physical fitness, and exercise adherence among the patients with SCI. Future studies should incorporate guidelines for home-based exercises and regular monitoring to promote long-term adherence to exercise and physical activity among individuals with SCI.

Relationship between anthropometric characteristics and aerobic fitness among Malaysian men and women.

This cross-sectional study evaluated the relationships between anthropometric and aerobic fitness (rate of perceived exertion [RPE] and predicted maximal oxygen uptake [VO2max]) among 228 participants (age: 23.78±4.42 years). RPE and predicted VO2max were determined during the cycle ergometer exercise test. Data were also obtained for height, weight, body mass index (BMI), hip and waist (WC) circumferences. Data analysis revealed VO2max is correlated with WC (r=-0.571), weight (r=-0.521), waist-to-height ratio (WHtR) (r=-0.516), waist-to-hip ratio (WHR) (r=-0.487), and BMI (r=-0.47) in men, while, in women with WC (r=-0.581), weight (r=-0.571), WHtR (r=-0.545), BMI (r=-0.545), WHR (r=-0.473), and height (r=-0.287) (all P<0.05). Regression analysis showed WC was a significant predictor for VO2max in men and women (r 2=32.6% vs. 33.7%). The receiver operating characteristic curve of WC showed 0.786 and 0.831 for men and women, respectively. WC or abdominal obesity is the strongest predictor for VO2max, which is an indicator of aerobic fitness in Malaysian adults.

Effectiveness of a 3-month antifalling program in the mobility, balance confidence, and muscle performance of older adults.

This study determined the effectiveness of a 3-month group-based multicomponent exercise program in the mobility, balance confidence, and muscle performance of older adults. A total of 40 participants (mean age=70.60±6.25 years completed pre- and posttest clinical intervention measures of mobility using the Timed Up and Go (TUG) test, balance confidence using the Activities-specific Balance Confidence scale, upper limb strength (handgrip dynamometer), and lower limb function (30-sec chair rise test). Data were analyzed using paired t-test and based on TUG criteria for risk of fall (low- and high-risk groups). Significant improvements were found in all measures (All P<0.05) following the 3-month program. Measures according to the risk of fall categories were also significantly improved (P<0.01), except the left handgrip strength (P>0.05). The low-risk group showed a higher improvement in mobility (14.87% vs. 11.74%), balance confidence (34.21% vs. 26.08%), and lower limb function (96.87% vs. 21.20%) but was not significantly different from the high-risk group (P>0.05). A group-based multicomponent exercise program benefited the physical functions of older adults at low- or high risk of falls.

Home-Based Physical Activity in Patients With Type 2 Diabetes Mellitus: A Scoping Review.

To promote optimal healthcare delivery in type 2 diabetes mellitus (T2DM) following the outbreak of coronavirus disease 2019, adopting home-based physical activity (PA) is being seriously considered. Therefore, this study aims to outline the characteristics of exercise protocols for home-based PA and the challenges and limitations in implementing home-based PA in patients with T2DM. This scoping review was carried out by identifying eligible studies in six different databases (Scopus, Cochrane Library, SpringerLink, ProQuest, Science Direct, and Google Scholar). The keywords used in the search strategies were: home-based physical activity, home-based exercise therapy, home-based physical exercise, home-based exercise, home-based exercise training, diabetes mellitus, and T2DM. Two reviewers independently screened all full-text articles to find articles that met the eligibility requirements. A total of 443 articles were identified in the search. Approximately 342 articles were excluded by screening titles and abstracts, which led to the selection of 44 articles relevant to the current study. Further screening of the full-text led to the subsequent removal of 34 other articles, leading to 10 studies that were eligible for data extraction. This review suggested that the exercise protocols for home-based PA include resistance exercise using free weight and own body weight with a frequency of two to three sessions per week at moderate intensity, along with aerobic exercise (particularly walking) with a frequency of three to five times per week at moderate intensity. A combination of resistance and aerobic exercise showed more significant benefits of PA in patients with T2DM. More studies regarding home-based PA in T2DM patients with metabolic disorders are warranted.

A multicomponent exercise program for institutionalized older adults.

This study examined the effects of a multicomponent exercise program on depression and quality of life in institutionalized older adults. A quasi-experimental pretest-posttest design was used. Participants were recruited from a publicly funded shelter home in Seremban, Negeri Sembilan Malaysia. The experimental group consisted of 23 volunteers 60 or older who performed 60 minutes of supervised exercise three times per week for 12 weeks. The control group consisted of 20 volunteers who continued with a sedentary lifestyle. At 12 weeks, the exercise group demonstrated an improvement in quality of life by 10.74% (p > 0.05) but not depression (-1.6%, p > 0.05). The control group demonstrated a decrease in both quality of life by 11.26% (p > 0.05) and level of depression by 17.7% (p > 0.05). This study suggests a multicomponent exercise program is a feasible intervention to improve quality of life in institutionalized older adults.

The effectiveness of patient education in improving pain, disability and quality of life among older people with low back pain: A systematic review.

OBJECTIVES: This study aimed to gain an overview of patient education and the effects of patient education for older people with low back pain (LBP). METHODS: The search strategies were performed via EBSCO MEDLINE, EBSCO CINAHL, Science Direct, PubMed, and PEDro databases from 2006 to 2016. The keywords "patient education", "low back pain", "elderly", "older adults", "older persons" and "older people" were used during the literature search. Boolean operators were used to expand or limit the searching scope and manual exclusion was performed to choose articles eligible for this study. RESULTS: A total of 2799 articles were retrieved but only five articles were related with patient education for older people with LBP. Findings suggest that patient education for older people may differ in terms of its contents such as health education, self-management, video education, and postural education. The high methodological quality of the studies revealed that patient education showed improvement in terms of pain, disability and quality of life among older people with LBP. CONCLUSIONS: Patient education improved pain and had positive effects on disability and quality of life among older people with LBP. However, due to the limited number of RCTs more studies are needed to provide evidence for its effectiveness.

Effects of Graded Exercises Integrated with Education on Physical Fitness, Exercise SelfEfficacy, and Activity Levels in People with Spinal Cord Injury: A Quasi-Experimental Study Protocol.

Study Design: A quasi-experimental single-blinded study. Purpose: To investigate the effects of 'graded exercise integrated with education' on physical fitness, exercise self-efficacy (ESE), and physical activity (PA) levels among subacute and chronic wheelchair-dependent paraplegia patients. Overview of Literature: Most of the chronic spinal cord injury (SCI) patients had low physical fitness due to a sedentary lifestyle and lack of ESE after discharge from a rehabilitation program. Education may encourage them to engage with exercise to regain and maintain their physical fitness. However, there is a lack of research to support the effects of exercise integrated with education after an SCI. Methods: A total of 44 participants will be assigned to either the experimental group (graded exercise integrated with education) or active control (conventional physical therapy). The experimental group will receive graded strength and aerobic exercise training according to their progression criteria. They will attend an education program during and after the rehabilitation program. The control group will only receive conventional physical therapy during their in-rehabilitation program. This study will be conducted during a period of 16 weeks, consisting of 8 weeks of in-rehabilitation and 8 weeks post-rehabilitation. Statistical analysis will be performed using the IBM SPSS ver. 21.0 (IBM Corp., Armonk, NY, USA) at a significance level of p≤0.05. Results: The primary outcome measures will be upper-limb isokinetic strength, isometric grip strength, and cardiorespiratory fitness. The secondary outcomes will be ESE and PA levels. Conclusions: An intervention that combines exercise training and education may be warranted to enhance the physical fitness, ESE, and PA levels in SCI patients. This trial was registered with ClinicalTrials.gov (NCT03420170).

Effects of Kinesio® Taping on Dynamic Balance Following Fatigue: a Randomized Controlled Trial.

The objective of the study was to determine the effects of Kinesio taping (KT) in inhibiting fatigue and preserving dynamic balance. Male recreational athletes were recruited to participate in this study. Participants were blinded from the group assignment and divided into four groups (Group A; KT and fatigue, Group B; no tape and fatigue, Group C; KT and no fatigue and Group D; no tape and no fatigue) using sequentially opaque, sealed envelopes. Pre and post measurements of Modified Star Excursion Balance Test (SEBT) composite score and normalized reach distance were used to measure dynamic balance. Adapted Functional Agility Short Term Fatigue Protocol (FAST-FP) was used to induce fatigue. KT was applied to rectus femoris, biceps femoris and medial gastrocnemius of the dominant leg. There was a significant change in the SEBT composite score between groups over time (p<0.05) and in time effect (p<0.05). The main effect comparing the SEBT composite score between the group was not significant (p=0.16). Group A (90.10±9.40) and Group B (86.14±10.50) attained lower mean for SEBT composite score compared to Group C (97.30±10.83) and Group D (98.13±9.47) suggests that fatigue have a diminishing effect on dynamic balance. KT application inhibit the effects of fatigue and preserved lateral and posterior direction of SEBT. KT application may lower the risk for injuries in the lateral and posterior directions following fatigue induction.

Axial Segmental Coordination During Turning: Effects of Stroke and Attentional Loadings.

Attentional loadings deteriorate straight walking performance for individuals poststroke, but its effects on turning while walking remain to be determined. Here we compared turning kinematics under three attentional loading conditions (single, dual-motor, and dual-cognitive task) between stroke survivors and healthy controls. Nine chronic stroke survivors and 10 healthy controls performed the Timed Upand- Go test while their full-body kinematics were recorded. Onset times of yaw rotation of the head, thorax and pelvis segments and head anticipation distance were used to quantify turning coordination. Results showed that stroke survivors reoriented their body segments much earlier than the controls, but they preserved the similar segmental reorientation sequence under the single-task condition. For the healthy controls, attentional loading led to an earlier axial segment reorientation, but the reorientation sequence was preserved. In contrast, the dual-cognitive task condition led to a disrupted reorientation sequence in stroke. The results indicate that turning coordination was altered in individuals poststroke, especially under the dual-task interference.

Kinesiophobia, Pain, Muscle Functions, and Functional Performances among Older Persons with Low Back Pain.

OBJECTIVES: This study aims (1) to determine the association between kinesiophobia and pain, muscle functions, and functional performances and (2) to determine whether kinesiophobia predicts pain, muscle functions, and functional performance among older persons with low back pain (LBP). METHODS: This is a correlational study, involving 63 institutionalized older persons (age = 70.98 ± 7.90 years) diagnosed with LBP. Anthropometric characteristics (BMI) and functional performances (lower limb function, balance and mobility, and hand grip strength) were measured. Muscle strength (abdominal and back muscle strength) was assessed using the Baseline® Mechanical Push/Pull Dynamometer, while muscle control (transverse abdominus and multifidus) was measured by using the Pressure Biofeedback Unit. The pain intensity and the level of kinesiophobia were measured using Numerical Rating Scale and Tampa Scale of Kinesiophobia, respectively. Data were analyzed using Pearson's correlation coefficients and multivariate linear regressions. RESULTS: No significant correlations were found between kinesiophobia and pain and muscle functions (all p > 0.05). Kinesiophobia was significantly correlated with mobility and balance (p = 0.038, r = 0.263). Regressions analysis showed that kinesiophobia was a significant predictor of mobility and balance (p = 0.038). CONCLUSION: We can conclude that kinesiophobia predicted mobility and balance in older persons with LBP. Kinesiophobia should be continuously assessed in clinical settings to recognize the obstacles that may affect patient's compliance towards a rehabilitation program in older persons with LBP.

The Effect of Diabetic Peripheral Neuropathy on Ground Reaction Forces during Straight Walking in Stroke Survivors.

Purpose. The aim of this present study was to investigate the ground reaction forces (GRFs) alterations in stroke survivors with diabetic peripheral neuropathy (DPN). Methods. Ten stroke survivors with DPN, 10 stroke survivors without DPN, and 10 healthy controls with matched body weight between groups participated in this case-control cross-sectional study. Three-dimensional GRFs (anterior-posterior, medial-lateral, and vertical) were collected at a comfortable walking speed using the Nexus Vicon motion analysis system and force plate. The Kruskal-Wallis test was used to analyze GRFs parameters. Results. We found significant alterations of medial-lateral forces of the nonparetic side and vertical forces of the paretic side in stroke survivors with DPN compared to stroke survivors without DPN and healthy controls. In addition, there were smaller braking and lower propulsion peak in anterior-posterior forces, smaller magnitude of medial-lateral forces, and lower first and second peak of vertical forces in stroke survivors with DPN compared to stroke survivors without DPN and healthy controls. Conclusion. The study findings identified that GRFs were affected in stroke survivors with DPN on both the paretic and the nonparetic sides. Further investigations are warranted to explore the impact of DPN on the kinematics and muscle activity related to the gait performance in stroke survivors with DPN.

Effectiveness of Strengthening Exercises for the Elderly with Low Back Pain to Improve Symptoms and Functions: A Systematic Review.

Objective. To determine the effect of strengthening exercises for older people with low back pain (LBP). Methods. This study is a systematic review of experimental study which evaluated the evidence regarding exercises for older people with LBP by using EBSCO Academic Search Premier, EBSCO EconLit, Science Direct, PUBMED, and PEDro from 2006 to 2016. Search strategy for each database was conducted by using keywords such as "low back pain", "older people", and "strengthening exercise". Boolean operators were used to combine keywords and manual exclusion was conducted to verify studies which met the inclusion criteria. The articles reviewed were evaluated and critically appraised by using PEDro scale and SPSS version 20 was used to analyze the data. Results. Three articles were found regarding strengthening exercise for older people with LBP whereas one study was conducted on multicomponent exercise. The mean, standard deviation, and variance of the PEDro score of all the studies were 5.67, 2.33, and 1.528, respectively. Overall, the qualities of all studies reviewed were fair. Two articles showed significant results when compared to control group (p < 0.05). Conclusions. Strengthening exercise is a beneficial treatment for older people with LBP in reducing pain intensity, disability, and improved functional performances.