Effects of two types of dynamic office workstations (DOWs) used at two intensities on cognitive performance and office work in tasks with various complexity.

This study examines the possible effects on objective work performance while using two types of dynamic office workstations (DOWs). 20 participants each used one type with three intensities (seated, light, moderate) and completed a task battery assessing cognitive performance and office work with two levels of complexity. Repeated measures MANOVA showed a significant interaction effect for work performance between the type of workstation and intensity for the simple level and a significant main effect for intensity for the complex level. Comparing the types of DOWs to each other, accuracy of text processing differed when working sedentary. Using both devices with light and moderate intensity had a significant detrimental effect on mouse tasks compared to working sedentary, but none comparing the intensities. No further results indicated neither a detrimental nor an enhancing effect of using DOWs on cognitive performance and office-work related tasks, regardless of the intensity of use or the task complexity. Practitioner Summary: By using DOWs, light physical activity can be integrated while working at a desk. Results showed that using different types of DOWs with different intensities does have a detrimental effect on tasks requiring a high motor control, but not on cognitive or further office work-related tasks of various complexity. Abbreviations: DOW: dynamic office workstation; aLT: activeLife Trainer; DB: deskbike; RPE: rated perceived exertion; MANOVA: multivariate analysis of variance; ANOVA: analysis of variance.

Body Image in Athletes and Nonathletes With Low Back Pain: Avoidance-Endurance-Related Subgroups and Sports Status Play a Role.

CONTEXT: Low back pain (LBP) is a serious health problem, both in the general population as well as in athletes. Research has shown that psychosocial aspects, such as dysfunctional pain responses, play a significant role in the chronification of LBP. Recent research supports the relevance of the multidisciplinary concept of body image in the interpretation of LBP. OBJECTIVE: To examine the differences in 2 psychosocial aspects, body image and pain responses, between athletes and nonathletes with LBP. DESIGN: Cross-sectional design. SETTING: The questionnaires were distributed in the course of LBP treatment. PARTICIPANTS: Data from 163 athletes (mean age = 28.69 [9.6] y) and 75 nonathletes (mean age = 39.34 [12.63] y) were collected. INTERVENTIONS: Data were collected by questionnaires assessing body image, pain behavior, training activity, and LBP. MAIN OUTCOME MEASURES: To examine group differences between athletes and nonathletes regarding body image and pain behavior, the authors performed 2-way analyses of variance with Bonferroni post hoc tests. RESULTS: The results showed (1) a significant main effect regarding pain responses and body image, showing that participants with eustress endurance or adaptive pain behavior revealed a more positive body image in both groups compared with participants with distress endurance or fear-avoidance behavior, and (2) a significant main effect for the factor group in the body image dimension of physical efficacy, indicating a more positive body image for athletes. CONCLUSION: These results suggest that considering multiple risk factors for LBP, such as body image and dysfunctional pain behavior, as well as subgrouping, might be valuable for research and for broadening therapy options.

Examining the Presence of Back Pain in Competitive Athletes: A Focus on Stress and Recovery.

CONTEXT: Explanatory approaches for back pain (BP) in athletes focus on biomechanical factors while neglecting psychological perspectives. Psychological factors have gained importance in the prediction of injuries in athletes and BP in the general population, with stress and recovery emerging as central risk factors. However, scarce evidence exists regarding the role of these aspects for the prevalent burden of BP. OBJECTIVE: To investigate the association between stress and recovery parameters and the presence of BP. DESIGN: Cross-sectional design. SETTING: The questionnaires were distributed after the training sessions. PARTICIPANTS: A total of 345 competitive athletes (mean age = 18.31 y [SD = 5.40]) were investigated. The classification of the athletes' competitive status was based on performance level. INTERVENTIONS: Data were collected using questionnaires for the assessment of stress, recovery, and BP. MAIN OUTCOME MEASURES: The authors performed a multiple logistic regression to obtain odds ratios for stress and recovery parameters with regard to the outcome variable BP status. RESULTS: For stress, the dimension "overall stress" (odds ratio = 1.83; 95% confidence interval, 1.30-2.59; P = .001) and the scale "physical complaints" (odds ratio = 1.68; 95% confidence interval, 1.25-2.25; P = .001) of the general version of the Recovery-Stress Questionnaire resulted to be significantly associated with BP. None of the recovery-related scales displayed a statistically significant relationship with BP. CONCLUSION: The outcomes of this study imply a modest association between stress and the presence of BP in competitive athletes. Practitioners may take these findings into account regarding the conception of training and for monitoring purposes.

Dynamic Office Workstations: Initial Insights into User Usability Evaluations and Motivation.

Dynamic office workstations present a promising way to address the problem of inactivity at work, as they combine light physical activity with office tasks. In order to overcome the lack of structured implementation of such devices in office environments and the difficulty of stimulating employees to engage in healthy behaviors, the aim of this study was to investigate employees' motivation and perceived usability (e.g. operability) regarding the use of dynamic office workstations. Two different types of devices were made available to 30 employees (13 females, 17 males, mean ± SD = 43 ± 11.51 years) for 6 weeks. Motivation to the use of the workstations was assessed pre- and post-intervention, and usability was assessed post-intervention. Descriptive statistics and Wilcoxon tests were conducted. Employees reported the usability of the workstations to be acceptable, as they did not impede their work activities, whilst they were autonomously motivated towards using either workstation. Dynamic office workstations are suitable for daily use, although a flexible use of such devices should be guaranteed, depending on the task at hand.

Assessing what generates precompetitive emotions: development of the precompetitive appraisal measure.

Athletes' precompetitive appraisal determines which emotion they experience with regard to an upcoming competition. Such precompetitive emotions have powerful and potentially destructive consequences for performance. To control and optimise these consequences, it is important to examine precompetitive appraisal. Currently, such efforts are hampered by the lack of a valid measurement tool. The present study aimed to develop a novel measure of precompetitive appraisal. Specifically, the Precompetitive Appraisal Measure (PAM) was constructed by adapting an existing self-report scale. Female and male intercollegiate team sport athletes (N = 384) completed the PAM, along with a measure of intensity and interpretation of precompetitive anxiety symptoms (CSAI-2D) prior to competition. On these responses, (a) a Principal Component Analysis and a Confirmatory Factor Analysis supported the PAM's suggested two-factor structure (Primary and Secondary Appraisal), (b) cluster analyses indicated the measure's ability to distinguish theoretically congruent appraisal profiles (Threat and Challenge) and (c) a MANOVA and multiple regression analyses demonstrated that PAM-responses predicted precompetitive symptom intensity and interpretation. Further, analyses revealed that the majority of athletes appraised the upcoming competition as a challenge.

Appraisal in a Team Context: Perceptions of Cohesion Predict Competition Importance and Prospects for Coping.

Athletes' precompetitive appraisal is important because it determines emotions, which may impact performance. When part of a team, athletes make their appraisal within a social context, and in this study we examined whether perceived team cohesion, as a characteristic of this context, related to appraisal. We asked 386 male and female intercollegiate team-sport athletes to respond to measures of cohesion and precompetitive appraisal before an in-season game. For males and females, across all teams, (a) an appraisal of increased competition importance was predicted by perceptions of higher task cohesion (individual level), better previous team performance, and a weaker opponent (team level) and (b) an appraisal of more positive prospects for coping with competitive demands was predicted by higher individual attractions to the group (individual level). Consequently, athletes who perceive their team as more cohesive likely appraise the pending competition as a challenge, which would benefit both emotions and performance.

[Do actual body experiences affect physical self-concept? A longitudinal study with patients with cardiac disease during sport therapy]. / Beeinflussen körperliche Erfahrungen das Körperkonzept? Eine Längschnittuntersuchung bei Herzpatienten im Rahmen von Sport- und Bewegungstherapie.

The present study investigates variations of physical well-being and physical self-concept during sport therapy in rehabilitation of patients with heart diseases. Additionally, interrelationships between physical self-concept and physical well-being were assumed. In a sample of 43 heart disease patients (aged 44-86), physical self-concept (PSK-scale) was assessed before and after a 3-week physical exercise treatment. Actual physical well-being was assessed with the Perceived Physical State adjective list (WKV) at 3 measuring points (beginning, mid, and end of sport therapy). Enhancements of physical self-concept and actual physical well-being could be found. Furthermore, relationships between both constructs could be revealed: The progression of one construct depends on the initial state of the respective other. Low initial states facilitate positive progression. These results are discussed both as a ceiling effect and as the consequence of a physical stimulation below threshold.

Social compensation of performance drops in dyadic exercises-Two experiments testing the role of relationship quality.

The purpose of this study was to analyze whether the social compensation of performance drops in a team setting depends on the relationship quality. Two experiments were conducted. Experiment 1: In a team-building condition, the relationship quality between subject and confederate was manipulated. The performance situation consisted of an isometric strength task. A joint team result had to be achieved in a second run, whereby the subject received manipulated feedback on the confederate's performance, hence suggesting a sudden drop. The results showed no compensation effect. Experiment 2: Given that one potential reason for the lack of effect appeared to be the isometric holding task, the study design was maintained, but the task was modified into a dynamic one. Performance drops were compensated for. However, the relationship quality did not affect compensation behavior. It is possible that implicit team building through the necessary joint agreement on goals interfered with the effect in both conditions.

Theoretical Derivation of a Telephone-Based Health Coaching Intervention for Promoting Physical Activity and Healthy Nutrition.

Present research regarding interventions to change behavior suffers from insufficient communication of their theoretical derivation. This insufficient communication is caused by the restrictions imposed by most of the relevant scientific journals. This impedes further intervention development. In this article, a telephone-based health coaching (TBHC) intervention is introduced using a format outside these restrictions. This intervention is seen as a combination of (1) the activities performed with the target persons, i.e., its core, and (2) measures to ensure the quality of the intervention. The theoretical derivation of the core is presented. The core is seen to consist of (1) the style of coach-patient interaction and (2) the contents of this interaction. The style of coach-patient interaction was derived from self-determination theory and was concretized using motivational interviewing techniques. The contents of the coach-patient interaction were derived from the health action process approach and were concretized using behavior-change techniques. The derivation led to (1) a set of 16 coaching tools referring to the different states in which a patient might be and containing state-specific recommendations for performing the coaching session, and (2) guidelines for selecting the appropriate coaching tool for each session. To ensure the quality of the intervention, a coach-training program before and supervision sessions during the TBHC were added.

Effects of an Impulse on the Sterno-Cleido-Mastoid Muscle on Back Pain, Discomfort, and Well-Being: A Randomized Controlled Trial in People with Low Back Pain.

INTRODUCTION: In the treatment of low back pain (LBP), passive regimens (e.g., relaxation) as opposed to active regimens (e.g., muscle training) may be a useful adjunct or, in certain cases, the only possible approach. Passive relaxation may be particularly useful for individuals who have lost the ability to adequately perceive relaxed muscles. The aim of the randomized controlled trial presented here was to investigate a specific and novel treatment for passive relaxation, namely, the Vitametik impulse (VI). METHODS: Participants (n = 135; 73.3% women; 26.7% men) were individuals with mild to moderate LBP aged from 19 to 76 years (M = 48.8). The participants were randomly assigned to one of four different groups (three different 8-week interventions, one control group). Pain, discomfort, and well-being were measured before and after the intervention period and at an 8-week follow-up. RESULTS: In the VI group, the decrease in various pain variables and discomfort was higher compared to the control group and compared to an education program (EP). There were no differences between the VI group and a combined VI/EP group. The effects remained stable until follow-up. CONCLUSION: VI appears to be an effective approach in the treatment of LBP, although the underlying mechanism remains unproven. Future studies should compare VI treatment with specific relaxation techniques or active muscle training. In addition, the results of the study need to be replicated.

Gaze behavior in social interactions between beach volleyball players-An exploratory approach.

Previous research has indicated that social interactions and gaze behavior analyses in a group setting could be essential tools in accomplishing group objectives. However, only a few studies have examined the impact of social interactions on group dynamics in team sports and their influence on team performance. This study aimed to investigate the effects of game performance pressure on the gaze behavior within social interactions between beach volleyball players during game-like situations. Therefore, 18 expert beach volleyball players conducted a high and a low game performance pressure condition while wearing an eye tracking system. The results indicate that higher game performance pressure leads to more and longer fixation on teammates' faces. A higher need for communication without misunderstandings could explain this adaptation. The longer and more frequent look at the face could improve the receiving of verbal and non-verbal information of the teammate's face. Further, players showed inter-individual strategies to cope with high game performance pressure regarding their gaze behavior, for example, increasing the number of fixations and the fixation duration on the teammate's face. Thereby, this study opens a new avenue for research on social interaction and how it is influenced in/through sport.

Motivational contagion during exercise and the role of interpersonal relationships: An experimental study.

The present research focused on the phenomenon of motivational contagion while being physically active. It can be assumed that communication with significant others impacts upon a person's behavior in situations where communication or interaction is not explicitly intended to change behavior. Specifically, the purpose of the two present studies was to examine the effect of positive (i.e., intrinsically connoted) and negative (i.e., extrinsically connoted) self-disclosure from a confederate on the motivational state of an individual simultaneously exercising with the confederate. These studies sought to replicate the experimental study of Scarapicchia, Andersen, & Bengoechea (2013). In addition, to test the further assumption that the relationship impacts upon contagion processes, we included a short team-building intervention involving our confederate and the participant in order to manipulate the relationship quality (Study 1) and to compare friends with strangers (Study 2). Our results show that the participants who were exposed to the intrinsic cues (e.g., "I enjoy riding the bike, it's great that there is a study about it") reported greater interest and enjoyment while exercising on the bicycle ergometer than those who were exposed to extrinsic cues (e.g., "I don't enjoy cycling at all. I'm only participating because my teacher told me to do so"). The relationship between the confederate and participant was not found to affect the main effect.

A pragmatic randomised controlled trial referring to a Personalised Self-management SUPport Programme (P-SUP) for persons enrolled in a disease management programme for type 2 diabetes mellitus and/or for coronary heart disease.

BACKGROUND: Type 2 diabetes mellitus (T2DM) and coronary heart disease (CHD) are two chronic diseases that cause a tremendous burden. To reduce this burden, several programmes for optimising the care for these diseases have been developed. In Germany, so-called disease management programmes (DMPs), which combine components of Disease Management and the Chronic Care Model, are applied. These DMPs have proven effective. Nevertheless, there are opportunities for improvement. Current DMPs rarely address self-management of the disease, make no use of peer support, and provide no special assistance for persons with low health literacy and/or low patient activation. The study protocol presented here is for the evaluation of a programme that addresses these possible shortcomings and can be combined with current German DMPs for T2DM and CHD. This programme consists of four components: 1) Meetings of peer support groups 2) Personalised telephone-based health coaching for patients with low literacy and/or low patient activation 3) Personalised patient feedback 4) A browser-based web portal METHODS: Study participants will be adults enrolled in a DMP for T2DM and/or CHD and living in North Rhine-Westphalia, a state of the Federal Republic of Germany. Study participants will be recruited with the assistance of their general practitioners by the end of June 2021. Evaluation will be performed as a pragmatic randomised controlled trial with one intervention group and one waiting control group. The intervention group will receive the intervention for 18 months. During this time, the waiting control group will continue with usual care and the usual measures of their DMPs. After 18 months, the waiting control group will also receive a shortened intervention. The primary outcome is number of hospital days. In addition, the effects on self-reported health-state, physical activity, nutrition, and eight different psychological variables will be investigated. Differences between values at month 18 and at the beginning will be compared to judge the effectiveness of the intervention. DISCUSSION: If the intervention proves effective, it may be included into the DMPs for T2DM and CHD. TRIAL REGISTRATION: The study was registered in the German Clinical Trials Registry (Deutsches Register Klinischer Studien (DRKS)) in early 2019 under the number 00020592. This registry has been affiliated with the WHO Clinical Trials Network ( https://www.drks.de/drks_web/setLocale_EN.do ) since 2008. It is based on the WHO template, but contains some additional categories for which information has to be given ( https://www.drks.de/drks_web/navigate.do?navigationId=entryfields&messageDE=Beschreibung%20der%20Eingabefelder&messageEN=Description%20of%20entry%20fields ). A release and subsequent number assignment only take place when information for all categories has been given.

Cohesion and adherence in exercise groups of patients with chronic heart diseases - a prospective study.

Objective: In cardiac rehabilitation, long-term adherence to exercise prescription is an important prerequisite to reduce mortality and the risk of recurrent cardiac events. Cohesion seems to be an important predictor of adherence when exercise is conducted in prevention settings, but in clinical settings, this relationship is currently unknown. To address this gap, the goal of this study was to determine the relationship between group cohesion and adherence in cardiac rehabilitation programs considering the duration of membership as a moderator.Design: The study was conducted with 474 participants (21.7% women), in three rehabilitation centres in North Rhine Westphalia, Germany, assessing cohesion, adherence and group membership in outpatient cardiac exercise groups.Main Outcome Measures: Cohesion was assessed using the KIT-FG and adherence was operationalized as the total number of sessions attended over a 7-week period.Results: Moderated hierarchical stepwise regression analyses revealed that perceptions of the social dimension of group cohesion significantly predicted adherence behaviour only for members with a rather long duration of membership.Conclusion: Our findings suggest that cohesion might have a differential effect on an individual's decision to regularly participate in exercise, depending on the duration of membership in the group.

Stress in Physical Education Teachers: A Systematic Review of Sources, Consequences, and Moderators of Stress.

Purpose: The purpose of this systematic review was to identify sources of stress, consequences of chronic stress and moderators of stress in physical education teachers and to formulate implications for future research and teacher education. Methods: The initial search identified 2483 publications, including 47 that met the inclusion criteria. Results: The most important sources of stress in physical education teachers were the curriculum, inadequate facilities/equipment, the low status of PE and students´ discipline problems. Regarding the consequences of chronic stress, the majority of studies assessed burnout and reported low to moderate levels of burnout in general. However, of the studies that reported percentages, 20-25% of physical education teachers indicated high levels of burnout. Conclusions: Regarding the relationship between sources of stress and consequences of chronic stress in physical education teachers, future studies should (a) take into account the whole stress process (b) use more adequate measures for stress and (c) address potential moderators of stress. In terms of practical implications, PE teachers should receive an adequate pre- and in-service training that aims at being aware of the main sources of stress in PE teachers and building up adequate coping strategies. In addition, PE teacher education should consider interventions to prevent health consequences of stress such as voice disorders.

The effect of parabolic flight on perceived physical, motivational and psychological state in men and women: correlation with neuroendocrine stress parameters and electrocortical activity.

Previous findings of decreased mental and perceptual motor performance during parabolic flights have been attributed mainly to the primary effects of weightlessness rather than the accompanying effects of stress and altered mood. Although recent studies have alluded to the possible negative effects of stress on performance, there has been no attempt to investigate this during parabolic flights. Over a period of 3 years, 27 human participants (male n = 18, mean age +/- SD 34.67 +/- 7.59 years; female n = 9, 36.22 +/- 9.92 years) were recruited with the aim to evaluate if, and to what extent, parabolic flights are accompanied by changes in mood. Furthermore, the relationships between mood and physiological markers of stress and arousal, namely circulating stress hormones (ACTH, cortisol, epinephrine, norepinephrine, prolactin and brain activity (EEG)) were investigated. A strong and significant correlation was found between circulating stress hormone concentrations and perceived physical state, motivational state (MOT) and psychological strain (PSYCHO), whereas no interaction between mood and EEG or EEG and stress hormone concentrations was observed. Therefore, two different stress responses appear to be present during parabolic flight. The first seems to be characterised by general cortical arousal, whereas the second seems to evolve from the adrenomedullary system. It is likely that both these mechanisms have different effects on mental and perceptual motor performance, which require further investigation and should to be taken into account when interpreting previous weightlessness research.

EEG activity and mood in health orientated runners after different exercise intensities.

An increasing number of studies within the recent years connected physical exercise with changes in brain cortical activity. Most of this data (1) refers to aerobic exercise and (2) does not correlate to psychological parameters although it is well known that exercise has a positive effect on mood. In times where health activities play a major role it is increasingly necessary to connect somato-physiological and somatopsychological components of physical activity. This study aimed to find changes in EEG activity and mood after low, preferred and high intensity running. EEG and actual state of mood were recorded before and after exercise. Results showed an effect for the preferred and high intensity velocity in both, EEG and mood. As only the higher frequency areas N18 Hz showed persisting decreases post-exercise we concluded that this might be a sign of outlasting effects of exercise on brain cortical activity which may have influences on general well-being. We could also show that there is a clear relationship between EEG activity and mood reflecting a basic principle of cortical excitation.

Early Risk Detection of Burnout: Development of the Burnout Prevention Questionnaire for Coaches.

Introduction: Previous research has shown that burnout develops as the result of a continuous imbalance between chronic stress and appropriate coping resources. Hence, the essential factors to measure burnout encompassed the factors stress and recovery within our studies. However, the Burnout Prevention Questionnaire for Coaches (BPQ-C) does not represent a new questionnaire from scratch, but rather a re-evaluated, condensed, and subsequently combined instrument with scales derived from validated psychometric instruments. Methods: The objective of study 1 (N = 233) was to create and evaluate the psychometric structure of the BPQ-C. The aim of study 2 (N = 473) consisted in the validation of the BPQ-C via a Confirmatory Factor Analysis. Results: The Exploratory Factor Analysis resulted in a model with three dimensions (Pre-Burnout, Resources, and Burnout). Via the subsequent Confirmatory Factor Analysis, the model could be confirmed with good fit indices (χ2 = 96.898, df = 19, p < 0.001, CFI = 0.973, SRMR = 0.044, RMSEA = 0.093, LO90 = 0.075, HI90 = 0.112). Conclusion: The BPQ-C includes a number of previously established risk and protective factors within a single psychometric instrument. The systematic application of the BPQ-C can help to detect critical conditions at an early stage in order to derive individualized and beneficial interventions for the respective coaches.

Body image is more negative in patients with chronic low back pain than in patients with subacute low back pain and healthy controls.

Background and aims Body image as an increasing research field has been integrated into pain research within the last years. However, research on cognitive-affective dimensions of body image dependent on different pain groups like acute/subacute and chronic pain patients, and healthy controls is still lacking. Therefore, this study aims to explore three dimensions of body image, namely self-acceptance, physical efficacy, and health in patients with low back pain and healthy controls. The present study is the first to distinguish between patients with low back pain in different stages of pain with regard to the concept of body image. In a second step we investigated the differences in exercise frequency between the three groups. Methods Seventy seven patients (53.2% female) suffering from low back pain and 57 healthy controls (42.1% female) filled in a battery of questionnaires in terms of body image, pain parameters and exercise frequency. Results Main results indicate first that patients suffering from chronic low back pain revealed a more negative body image in all three body image-dimensions than healthy controls. Second, patients suffering from subacute pain revealed a more negative body image of physical efficacy compared to the healthy controls. Conclusions Our results suggest that body image is relevant for the treatment of low back pain, because patients suffering from low back pain revealed a more negative body image than healthy controls. Implications To investigate the cognitive-affective dimensions of body image in different patient groups suffering from low back pain seems to be an important aspect for future research to improve therapy options and prevention of low back pain. Future research should also focus on improvements or on positive aspects of body image in patients with low back pain.

Depression and suicidal ideation in high-performance athletes suffering from low back pain: The role of stress and pain-related thought suppression.

BACKGROUND: Depression and suicidal ideation are important health problems in athletes suffering from pain. Dysfunctional pain cognitions, that is, pain-related thought suppression (PTS), may play an important role in their aetiology. Thought suppression was shown to increase depressive mood, particularly in highly stressed individuals. This cross-sectional study examines the relationship between PTS and stress on depression and suicidal ideation in athletes with pain. METHODS: A total of 159 athletes with non-specific low back pain completed a set of questionnaires to measure PTS, depression and stress. Participants were split into groups with high and low stress, and high and low PTS. Two-way ANOVA calculated main effects for PTS, stress and a PTS*stress interaction, with depressive symptoms as dependent. Subsequently, distribution tests were calculated, investigating if the presence of clinically relevant depression and suicidal ideation is dependent of conditions of high/low PTS and stress. RESULTS: A main effect of stress demonstrated higher depression scores in highly stressed athletes. Further, a significant PTS*stress interaction showed elevated depression scores in athletes with high PTS and high stress. Distribution analysis revealed positive associations between PTS, stress and depression, with depression being most frequent among athletes with high PTS and high stress. Suicidal ideation was not significantly associated with PTS and only weakly correlated with stress. CONCLUSIONS: Our findings show that PTS is the most common pain response in athletes with pain. The results indicate a higher prevalence of depression and elevated depressive symptoms in athletes experiencing high stress, seemingly more pronounced when highly engaging in PTS. SIGNIFICANCE: This study contributes to the understanding of depression in athletes with pain, suggesting stress and pain-related thought suppression to increase symptoms and prevalence of depression. As athletes often experience acute or chronic pain, understanding the impact of pain cognitions on health outcomes is an important step in the optimization of treatments.