Going Green Post COVID-19: Employer Perspectives on Skills Needs.

Achieving a just transition to a low carbon economy and society, in the wake of the COVID-19 pandemic, is arguably one of the greatest policy challenges facing governments. It is also of deep concern to businesses, employees and the organisations that represent them. Much of the focus, particularly at policy level, has been on the potential of this transition to create new jobs especially through the growth of renewable energy and clean technology. In this paper, we argue that this focus on 'green jobs', and in particular new green jobs, grossly underestimates the skills needs of a future workforce able to deliver a transition to a more sustainable low-carbon economy. The focus of this study is to gain an understanding of what skills are required to support the transition beyond these sectors. It critically reports on the results of a series of in-depth interviews with senior managers in key organisations within Cambridgeshire and Peterborough, UK. It sheds a light on the significant employment transitions taking place in organisations who are not specifically focused on delivering 'green' products or services. It finds widespread acknowledgement of the importance of a green recovery, albeit predicated by economic growth. The key skills needs reported, at all levels were likely to be 'soft' transferrable skills rather than 'hard' technical skills. COVID-19 was recognised as both a disrupter and as a catalyst for a green transition.

Successful delivery of nutrition programs and the sustainable development goals.

Malnutrition affects millions of people globally, especially women, children, and other vulnerable populations. Sustainable Development Goals (SDGs) were set in 2015 to end poverty, protect the planet, and improve the lives and prospects of everyone by 2030. To achieve the SDG goals effective nutrition interventions and programs need to be efficiently delivered to those most in need. Nutrition directly affects 2 SDGs (2 and 3) and indirectly influences five others. In addition, almost all SDGs influence nutrition and thus attaining the SDG goals is also a pre-requisite to achieving the Global Nutrition targets set in 2012. Evidence-based nutrition interventions, for which there is strong evidence of their biological impact, have the potential to directly influence SDGs 2 and 3 if successfully delivered at scale in high-burden countries. Nevertheless, delivery of nutrition programs is a complex process, where policy, government commitment, adequate budget allocation, supplies and delivery systems, training of service providers, informed beneficiaries and program monitoring and evaluation all need to be in place and aligned with each other. Although in the past decade there has been progress in the SDGs that nutrition directly affects, many goals are still off-track, likely due to several pending gaps at policy-level, program-level, and intervention-level. To accelerate the progress toward reaching the SDG goals that are directly influenced by nutrition, countries need to be supported to successfully and sustainably deliver proven interventions and to scale-up and deliver new interventions in new and innovative ways, and the evidence base should be built in promising areas especially integrating (rather than prioritizing over each other) nutrition-specific and sensitive approaches.

Refocusing vitamin A supplementation programmes to reach the most vulnerable.

WHO recommends vitamin A supplementation (VAS) programmes for children 6-59 months where vitamin A deficiency is a public health problem. However, resources for VAS are falling short of current needs and programme coverage is suffering. The authors present the case for considering the options for shifting efforts and resources from a generalised approach, to prioritising resources to reach populations with continued high child mortality rates and high vitamin A deficiency prevalence to maximise child survival benefits . This includes evaluating where child mortality and/or vitamin A deficiency has dropped, as well as using under 5 mortality rates as a proxy for vitamin A deficiency, in the absence of recent data. The analysis supports that fewer countries may now need to prioritise VAS than in the year 2000, but that there are still a large number of countries that do. The authors also outline next steps for analysing options for improved targeting and cost-effectiveness of programmes. Focusing VAS resources to reach the most vulnerable is an efficient use of resources and will continue to promote young child survival.

Confidence and Attitudes Toward Osteoarthritis Care Among the Current and Emerging Health Workforce: A Multinational Interprofessional Study.

OBJECTIVE: To measure confidence and attitudes of the current and emerging interprofessional workforce concerning osteoarthritis (OA) care. METHODS: Study design is a multinational (Australia, New Zealand, Canada) cross-sectional survey of clinicians (general practitioners [GPs], GP registrars, primary care nurses, and physiotherapists) and final-year medical and physiotherapy students. GPs and GP registrars were only sampled in Australia/New Zealand and Australia, respectively. The study outcomes are as follows: confidence in OA knowledge and skills (customized instrument), biomedical attitudes to care (Pain Attitudes Beliefs Scale [PABS]), attitudes toward high- and low-value care (customized items), attitudes toward exercise/physical activity (free-text responses). RESULTS: A total of 1886 clinicians and 1161 students responded. Although a number of interprofessional differences were identified, confidence in OA knowledge and skills was consistently greatest among physiotherapists and lowest among nurses (eg, the mean difference [95% confidence interval (CI)] for physiotherapist-nurse analyses were 9.3 [7.7-10.9] for knowledge [scale: 11-55] and 14.6 [12.3-17.0] for skills [scale: 16-80]). Similarly, biomedical attitudes were stronger in nurses compared with physiotherapists (6.9 [5.3-8.4]; scale 10-60) and in medical students compared with physiotherapy students (2.0 [1.3-2.7]). Some clinicians and students agreed that people with OA will ultimately require total joint replacement (7%-19% and 19%-22%, respectively), that arthroscopy is an appropriate intervention for knee OA (18%-36% and 35%-44%), and that magnetic resonance imaging is informative for diagnosis and clinical management of hip/knee OA (8%-61% and 21%-52%). Most agreed (90%-98% and 92%-97%) that exercise is indicated and strongly supported by qualitative data. CONCLUSION: Workforce capacity building that de-emphasizes biomedical management and promotes high-value first-line care options is needed. Knowledge and skills among physiotherapists support leadership roles in OA care for this discipline.

Delivering Vitamin A Supplements to Children Aged 6-59 Months: Comparing Delivery through Campaigns and through Routine Health Services in Senegal.

BACKGROUND: Using twice-yearly campaigns such as Child Health Days to deliver vitamin A supplements has been a key strategy over the last 2 decades, and was an important component in helping reach the Millennium Development Goals in child health. As countries move to strengthen their routine health services under the Sustainable Development Goals, efforts are underway to shift supplementation from campaign to routine delivery. OBJECTIVE: The aim of this study was to compare cost, coverage, and user satisfaction between twice-yearly campaigns and routine delivery of vitamin A supplements in Senegal. METHODS: Information was collected on cost, coverage, and user satisfaction with both types of delivery, using administrative data, interviews at various levels in the health system, and focus group discussions with caregivers. Both qualitative and quantitative information were obtained, for 2 regions using routine delivery and 2 regions using campaign delivery. RESULTS: Routine delivery receives fewer dedicated resources. Coverage is lower, especially of children >12 mo of age. Districts undertake outreach ("mini-campaigns") to try to improve coverage in regions using routine delivery, in effect using a hybrid approach. Some mothers prefer the administration of supplements at a health facility as it is perceived as more hygienic and involving professional health workers, but others, especially those living further away, prefer house-to-house delivery which was the norm for the campaign mode. CONCLUSIONS: Advance planning for the shift to routine delivery is important in maintaining coverage, as is strengthening the primary health care system by having an appropriate ratio of salaried workers to population. When the system relies heavily on volunteers, and the small incentive payments to volunteers are discontinued, coverage suffers. Routine delivery also relies on good record-keeping and hence literacy. Community understanding of, and support for, supplementation are even more important for routine than for campaign delivery.

Delivering Vitamin A Supplements to Children Aged 6 to 59 Months: Comparing Delivery Through Mass Campaign and Through Routine Health Services in Ethiopia.

BACKGROUND: The delivery of vitamin A supplements in Ethiopia has been shifting from Child Health Days (campaigns) to routine delivery via the community health services. OBJECTIVE: The objective of this study was to compare the cost and effectiveness of these 2 delivery methods. No previous studies have done this. METHODS: A mixed method approach was used. Quantitative data on costs were collected from interviews with key staff and coverage data from health facility records. Qualitative data on the 2 modalities were collected from key informants and community members from purposefully sampled communities using the 2 modalities. RESULTS: Communities appreciated the provision of vitamin A supplements to their under 5-year-old children. The small drop in coverage that occurred as a result of the change in modality can be attributed to normal changes that occur with any system change. Advantages of campaigns included greater ease of mobilization and better coverage of older children from more remote communities. Advantages of routine delivery included not omitting children who happened to miss the 1 day per round that supplementation occurred and not disrupting the availability of other health services for the 5 to 6 days each campaign requires. The cost of routine delivery is not easy to measure nor is the cost of disruption to normal services entailed by campaigns. CONCLUSION: Cost-effectiveness likely depends more on effectiveness than on cost. Overall, the routine approach can achieve good coverage and is sustainable in the long run, as long as the transition is well planned and implemented.

Vitamin A Supplementation Programs and Country-Level Evidence of Vitamin A Deficiency.

Vitamin A supplementation (VAS) programs targeted at children aged 6-59 months are implemented in many countries. By improving immune function, vitamin A (VA) reduces mortality associated with measles, diarrhea, and other illnesses. There is currently a debate regarding the relevance of VAS, but amidst the debate, researchers acknowledge that the majority of nationally-representative data on VA status is outdated. To address this data gap and contribute to the debate, we examined data from 82 countries implementing VAS programs, identified other VA programs, and assessed the recentness of national VA deficiency (VAD) data. We found that two-thirds of the countries explored either have no VAD data or data that were >10 years old (i.e., measured before 2006), which included twenty countries with VAS coverage ≥70%. Fifty-one VAS programs were implemented in parallel with at least one other VA intervention, and of these, 27 countries either had no VAD data or data collected in 2005 or earlier. To fill these gaps in VAD data, countries implementing VAS and other VA interventions should measure VA status in children at least every 10 years. At the same time, the coverage of VA interventions can also be measured. We identified three countries that have scaled down VAS, but given the lack of VA deficiency data, this would be a premature undertaking in most countries without appropriate status assessment. While the global debate about VAS is important, more attention should be directed towards individual countries where programmatic decisions are made.

A Changing Landscape for Vitamin A Programs: Implications for Optimal Intervention Packages, Program Monitoring, and Safety.

BACKGROUND: Vitamin A deficiency (VAD) remains a widespread public health problem in the developing world, despite changes in under-5 mortality rates, morbidity patterns, and intervention options. OBJECTIVE: This article considers the implications of a changing epidemiologic and programmatic landscape for vitamin A (VA) programs. METHODS: We review progress to prevent VAD and its health consequences, assess gaps in VA status and intervention coverage data, and assess data needed to guide decisions regarding the optimal mix, targeting, and dose of VA interventions to maximize benefit and minimize risk. RESULTS: Vitamin A supplementation programs have contributed to the reduction in under-5 mortality rates, but alone, do not address the underlying problem of inadequate dietary VA intakes and VAD among preschool-aged children in the developing world. A combination of VA interventions (eg, supplementation, fortified foods, multiple micronutrient powders, and lipid-based nutrient supplements) will be required to achieve VA adequacy in most settings. Current efforts to measure the coverage of multiple VA interventions, as well as whether and how much VA children are receiving, are few and fragmented. CONCLUSIONS: Where intervention overlap exists, further effort is needed to monitor VA intakes, ensuring that targeted groups are consuming adequate amounts but not exceeding the tolerable upper intake level. Vitamin A status data will also be critical for navigating the changing landscape of VA programs. Data from these monitoring efforts will help to guide decisions on the optimal mix, targeting, and exposure to VA interventions to maximize public health benefit while minimizing any potential risk.

Raising the Priority of Lifestyle-Related Noncommunicable Diseases in Physical Therapy Curricula.

Given their enormous socioeconomic burdens, lifestyle-related noncommunicable diseases (heart disease, cancer, chronic lung disease, hypertension, stroke, type 2 diabetes mellitus, and obesity) have become priorities for the World Health Organization and health service delivery systems. Health care systems have been criticized for relative inattention to the gap between knowledge and practice, as it relates to preventing and managing noncommunicable diseases. Physical therapy is a profession that can contribute effectively to patients'/clients' lifestyle behavior changes at the upstream end of prevention and management. Efforts by entry-to-practice physical therapist education programs to align curricula with epidemiological trends toward best health care practices are varied. One explanation may be the lack of a frame of reference for reducing the knowledge translation gap. The purpose of this article is to provide a current perspective on epidemiological indicators and societal priorities to inform physical therapy curriculum content. Such content needs to include health examination/evaluation tools and health behavior change interventions that are consistent with contemporary values, directions, and practices of physical therapy. These considerations provide a frame of reference for curriculum change. Based on 5 years of experience and dialogue among curriculum stakeholders, an example of how epidemiologically informed and evidence-based best health care practices may be systematically integrated into physical therapy curricula to maximize patient/client health and conventional physical therapy outcomes is provided. This novel approach can serve as an example to other entry-to-practice physical therapist education programs of how to align their curricula with societal health priorities, specifically, noncommunicable diseases. The intentions are to stimulate dialogue about effectively integrating health-based competencies into entry-level education and advancing best practice, as opposed to simply evidence-based practice, across professions and health services and to establish accreditable, health promotion practice standards for physical therapy.

Trunk muscle activity is modified in osteoporotic vertebral fracture and thoracic kyphosis with potential consequences for vertebral health.

This study explored inter-relationships between vertebral fracture, thoracic kyphosis and trunk muscle control in elderly people with osteoporosis. Osteoporotic vertebral fractures are associated with increased risk of further vertebral fractures; but underlying mechanisms remain unclear. Several factors may explain this association, including changes in postural alignment (thoracic kyphosis) and altered trunk muscle contraction patterns. Both factors may increase risk of further fracture because of increased vertebral loading and impaired balance, which may increase falls risk. This study compared postural adjustments in 24 individuals with osteoporosis with and without vertebral fracture and with varying degrees of thoracic kyphosis. Trunk muscle electromyographic activity (EMG) associated with voluntary arm movements was recorded and compared between individuals with and without vertebral fracture, and between those with low and high thoracic kyphosis. Overall, elderly participants in the study demonstrated co-contraction of the trunk flexor and extensor muscles during forwards arm movements, but those with vertebral fractures demonstrated a more pronounced co-contraction than those without fracture. Individuals with high thoracic kyphosis demonstrated more pronounced alternating flexor and extensor EMG bursts than those with less kyphosis. Co-contraction of trunk flexor and extensor muscles in older individuals contrasts the alternating bursts of antagonist muscle activity in previous studies of young individuals. This may have several consequences, including altered balance efficacy and the potential for increased compressive loads through the spine. Both of these outcomes may have consequences in a population with fragile vertebrae who are susceptible to fracture.

Program evaluation of a model to integrate internationally educated health professionals into clinical practice.

BACKGROUND: The demand for health professionals continues to increase, partially due to the aging population and the high proportion of practitioners nearing retirement. The University of British Columbia (UBC) has developed a program to address this demand, by providing support for internationally trained Physiotherapists in their preparation for taking the National Physiotherapy competency examinations.The aim was to create a program comprised of the educational tools and infrastructure to support internationally educated physiotherapists (IEPs) in their preparation for entry to practice in Canada and, to improve their pass rate on the national competency examination. METHODS: The program was developed using a logic model and evaluated using program evaluation methodology. Program tools and resources included educational modules and curricular packages which were developed and refined based on feedback from clinical experts, IEPs and clinical physical therapy mentors. An examination bank was created and used to include test-enhanced education. Clinical mentors were recruited and trained to provide clinical and cultural support for participants. RESULTS: The IEP program has recruited 124 IEPs, with 69 now integrated into the Canadian physiotherapy workforce, and more IEPs continuing to apply to the program. International graduates who participated in the program had an improved pass rate on the national Physiotherapy Competency Examination (PCE); participation in the program resulted in them having a 28% (95% CI, 2% to 59%) greater possibility of passing the written section than their counterparts who did not take the program. In 2010, 81% of all IEP candidates who completed the UBC program passed the written component, and 82% passed the clinical component. CONCLUSION: The program has proven to be successful and sustainable. This program model could be replicated to support the successful integration of other international health professionals into the workforce.

Evaluating students' perceptions of an interprofessional problem-based pilot learning project.

Interprofessional teams provide the promise of effective, comprehensive and reliable care. Interprofessional education (IPE) promotes students' knowledge and attitudes to support interprofessional teamwork, and problem-based learning formats enable students to gain valuable teamwork experience. AIM/DESIGN: To design, implement, and evaluate an interprofessional problem-based learning module in a large Canadian university focusing on the effects of this format on students' knowledge, attitudes, and perceptions. A pre-post mixed-methods research design was used, with a convenience sample of 24 students from medicine, pharmacy, nursing, physical therapy, and occupational therapy. Participants in the module were divided into 5 teams composed of one member from each discipline. Pre-tests were delivered just prior to module participation and post-tests directly followed. Students also participated in focus groups to provide feedback about module content, process, outcomes, and practical considerations. RESULTS: Students' attitudes toward interprofessional teamwork improved from baseline to post-intervention. Mean differences were significant using paired t-tests on confidence in professional role (p <0.001), communication (p = 0.02), understanding roles of others (p = 0.002), identification with the team (p = 0.002), comfort with members (p = 0.047), cooperation with team members (p = 0.004), team perceptions (p = 0.04), decision-making (p <0.001), team efficiency (p <0.001), minimal conflict (p = 0.04), and group contributions (p = 0.03). Focus group themes indicated students were satisfied with the module, perceived increased knowledge about roles and perspectives, greater confidence to collaborate, and increased motivation to engage in intra-curricular IPE. The timing of their exposure within their respective educational programs was identified as important.

Effects of an exercise and manual therapy program on physical impairments, function and quality-of-life in people with osteoporotic vertebral fracture: a randomised, single-blind controlled pilot trial.

BACKGROUND: This randomised, single-blind controlled pilot trial aimed to determine the effectiveness of a physiotherapy program, including exercise and manual therapy, in reducing impairments and improving physical function and health-related quality of life in people with a history of painful osteoporotic vertebral fracture. METHODS: 20 participants were randomly allocated to an intervention (n = 11) or control (n = 9) group. The intervention group attended individual sessions with an experienced clinician once a week for 10 weeks and performed daily home exercises with adherence monitored by a self-report diary. The control group received no treatment. Blinded assessment was conducted at baseline and 11 weeks. Questionnaires assessed self-reported changes in back pain, physical function, and health-related quality of life. Objective measures of thoracic kyphosis, back and shoulder muscle endurance (Timed Loaded Standing Test), and function (Timed Up and Go test) were also taken. RESULTS: Compared with the control group, the intervention group showed significant reductions in pain during movement (mean difference (95% CI) -1.8 (-3.5 to -0.1)) and at rest (-2.0 (-3.8 to -0.2)) and significantly greater improvements in Qualeffo physical function (-4.8 (-9.2 to -0.5)) and the Timed Loaded Standing test (46.7 (16.1 to 77.3) secs). For the perceived change in back pain over the 10 weeks, 9/11 (82%) participants in the intervention group rated their pain as 'much better' compared with only 1/9 (11%) participants in the control group. CONCLUSION: Despite the modest sample size, these results support the benefits of exercise and manual therapy in the clinical management of patients with osteoporotic vertebral fractures, but need to be confirmed in a larger sample. TRIAL REGISTRATION: NCT00638768.

Postural taping decreases thoracic kyphosis but does not influence trunk muscle electromyographic activity or balance in women with osteoporosis.

BACKGROUND: Greater thoracic kyphosis is associated with increased biomechanical loading of the spine which is potentially problematic in individuals with osteoporotic vertebral fractures. Conservative interventions that reduce thoracic kyphosis warrant further investigation. This study aimed to investigate the effects of therapeutic postural taping on thoracic posture. Secondary aims explored the effects of taping on trunk muscle activity and balance. METHODS: Fifteen women with osteoporotic vertebral fractures participated in this within-participant design study. Three taping conditions were randomly applied: therapeutic taping, control taping and no taping. Angle of thoracic kyphosis was measured after each condition. Force plate-derived balance parameters and trunk muscle electromyographic activity (EMG) were recorded during three static standing tasks of 40s duration. RESULTS: There was a significant main effect of postural taping on thoracic kyphosis (p=0.026), with a greater reduction in thoracic kyphosis after taping compared with both control tape and no tape. There were no effects of taping on EMG or balance parameters. CONCLUSIONS: The results of this study demonstrate that the application of postural therapeutic tape in a population with osteoporotic vertebral fractures induced an immediate reduction in thoracic kyphosis. Further research is needed to investigate the underlying mechanisms associated with this decrease in kyphosis.

Thoracic kyphosis affects spinal loads and trunk muscle force.

BACKGROUND AND PURPOSE: Patients with increased thoracic curvature often come to physical therapists for management of spinal pain and disorders. Although treatment approaches are aimed at normalizing or minimizing progression of kyphosis, the biomechanical rationales remain unsubstantiated. SUBJECTS: Forty-four subjects (mean age [+/-SD]=62.3+/-7.1 years) were dichotomized into high kyphosis and low kyphosis groups. METHODS: Lateral standing radiographs and photographs were captured and then digitized. These data were input into biomechanical models to estimate net segmental loading from T2-L5 as well as trunk muscle forces. RESULTS: The high kyphosis group demonstrated significantly greater normalized flexion moments and net compression and shear forces. Trunk muscle forces also were significantly greater in the high kyphosis group. A strong relationship existed between thoracic curvature and net segmental loads (r =.85-.93) and between thoracic curvature and muscle forces (r =.70-.82). DISCUSSION AND CONCLUSION: This study provides biomechanical evidence that increases in thoracic kyphosis are associated with significantly higher multisegmental spinal loads and trunk muscle forces in upright stance. These factors are likely to accelerate degenerative processes in spinal motion segments and contribute to the development of dysfunction and pain.

Paraspinal muscle control in people with osteoporotic vertebral fracture.

The high risk of sustaining subsequent vertebral fractures after an initial fracture cannot be explained solely by low bone mass. Extra-osseous factors, such as neuromuscular characteristics may help to explain this clinical dilemma. Elderly women with (n = 11) and without (n = 14) osteoporotic vertebral fractures performed rapid shoulder flexion to perturb the trunk while standing on a flat and short base. Neuromuscular postural responses of the paraspinal muscles at T6 and T12, and deep lumbar multifidus at L4 were recorded using intramuscular electromyography (EMG). Both groups demonstrated bursts of EMG that were initiated either before or shortly after the onset of shoulder flexion (P < 0.05). Paraspinal and multifidus onset occurred earlier in the non-fracture group (50-0 ms before deltoid onset) compared to the fracture group (25 ms before and 25 ms after deltoid onset) in the flat base condition. In the short base condition, EMG amplitude increased significantly above baseline earlier in the non-fracture group (75-25 ms before deltoid onset) compared to the fracture group (25-0 ms before deltoid onset) at T6 and T12; yet multifidus EMG increased above baseline earlier in the fracture group (50-25 ms before deltoid) compared to the non-fracture group (25-0 ms before deltoid). Time to reach maximum amplitude was shorter in the fracture group. Hypothetically, the longer time to initiate a postural response and shorter time to reach maximum amplitude in the fracture group may indicate a neuromuscular contribution towards subsequent fracture aetiology. This response could also be an adaptive characteristic of the central nervous system to minimise vertebral loading time.

The effect of osteoporotic vertebral fracture on predicted spinal loads in vivo.

The aetiology of osteoporotic vertebral fractures is multi-factorial, and cannot be explained solely by low bone mass. After sustaining an initial vertebral fracture, the risk of subsequent fracture increases greatly. Examination of physiologic loads imposed on vertebral bodies may help to explain a mechanism underlying this fracture cascade. This study tested the hypothesis that model-derived segmental vertebral loading is greater in individuals who have sustained an osteoporotic vertebral fracture compared to those with osteoporosis and no history of fracture. Flexion moments, and compression and shear loads were calculated from T2 to L5 in 12 participants with fractures (66.4 +/- 6.4 years, 162.2 +/- 5.1 cm, 69.1 +/- 11.2 kg) and 19 without fractures (62.9 +/- 7.9 years, 158.3 +/- 4.4 cm, 59.3 +/- 8.9 kg) while standing. Static analysis was used to solve gravitational loads while muscle-derived forces were calculated using a detailed trunk muscle model driven by optimization with a cost function set to minimise muscle fatigue. Least squares regression was used to derive polynomial functions to describe normalised load profiles. Regression co-efficients were compared between groups to examine differences in loading profiles. Loading at the fractured level, and at one level above and below, were also compared between groups. The fracture group had significantly greater normalised compression (p = 0.0008) and shear force (p < 0.0001) profiles and a trend for a greater flexion moment profile. At the level of fracture, a significantly greater flexion moment (p = 0.001) and shear force (p < 0.001) was observed in the fracture group. A greater flexion moment (p = 0.003) and compression force (p = 0.007) one level below the fracture, and a greater flexion moment (p = 0.002) and shear force (p = 0.002) one level above the fracture was observed in the fracture group. The differences observed in multi-level spinal loading between the groups may explain a mechanism for increased risk of subsequent vertebral fractures. Interventions aimed at restoring vertebral morphology or reduce thoracic curvature may assist in normalising spine load profiles.