Rehabilitation and Therapy Commons^™

An Umbrella Review Of Self-Management Interventions For Health Conditions With Symptom Overlap With Traumatic Brain Injury, Angelle Sander, Monique Pappadis, Tamara Bushnik, Nancy Chiaravalloti, Simon Driver, Robin Hanks, Kirk Lercher, Dawn Neumann, Amanda Rabinowitz, Ronald T Seel, Erica Weber, Rick Ralston, John Corrigan, Kurt Kroenke, Flora Hammond

Department of Rehabilitation Medicine Faculty Papers

OBJECTIVE: To synthesize evidence for the effectiveness of self-management interventions for chronic health conditions that have symptom overlap with traumatic brain injury (TBI) in order to extract recommendations for self-management intervention in persons with TBI.

DESIGN: An umbrella review of existing systematic reviews and/or meta-analyses of randomized controlled trials or nonrandomized studies targeting self-management of chronic conditions and specific outcomes relevant to persons with TBI.

METHOD: A comprehensive literature search of 5 databases was conducted using PRISMA guidelines. Two independent reviewers conducted screening and data extraction using the Covidence web-based review platform. Quality assessment was conducted using criteria adapted from …

Multifactorial Exercise Intervention Decreases Falls Risk In High-Risk And Low-Risk Older Adults, Amanda Estep, Steven Morrison, Shane V. Caswell, Jatin P. Ambegaonkar, João R. Vaz, Nelson Cortes

Rehabilitation Sciences Faculty Publications

Background: Each year, 1 in 4 people over the age of 65 years of age will experience a fall. It is important to identify and address modifiable risk factors that are associated with falls in adults at high and low risk for falls.

Hypothesis: Falls risk improves in both high-risk and low-risk participants with the implementation of Stay Active and Independent for Life (SAIL).

Study Design: Cohort study.

Level of Evidence: Level 3.

Methods: Seventy-eight older adults (age, 70.9 ± 5.1 years) were included in this study and categorized into high risk and low risk for falling based on the …

Examining Rehabilitation Referral Patterns For Breast Cancer Patients With Mastectomy: A Retrospective Descriptive Chart Review, Jessie Perchaluk, Ms, Otr/L, Cht

Post-Professional Occupational Therapy Doctorate Culminating Presentations

Introduction: Advances in health care for those with breast cancer (BC), have led to people living longer lives, however many continue to have difficulty completing daily activities (Hwang et al., 2015; Keesing et al., 2018; Lovelace et al., 2019; Stout et al., 2015; Stubblefield, ). Research explains that physical rehabilitation is beneficial for people with BC, however is not always being recommended (Cheville et al., 2008; Hwang et al., 2015; Pergoletti, 2014; Rafn et al., 2020; Stout et al., 2016; Stout et al., 2015).

Objectives: This study looked at rehabilitation referral patterns and trends for women diagnosed with BC who …

Electric Field Navigated 1-Hz Rtms For Poststroke Motor Recovery: The E-Fit Randomized Controlled Trial, Dylan J. Edwards, Charle Y. Liu, Kari Dunning, Felipe Fregni, Jarmo Laine, Benjamin E. Leiby, Lynn M. Rogers, Richard L. Harvey

Moss-Magee Rehabilitation Papers

BACKGROUND: To determine if low-frequency repetitive transcranial magnetic stimulation targeting the primary motor cortex contralateral (M1_CL) to the affected corticospinal tract in patients with hemiparetic stroke augments intensive training–related clinical improvement; an extension of the NICHE trial (Navigated Inhibitory rTMS to Contralesional Hemisphere Trial) using an alternative sham coil.

METHODS: The present E-FIT trial (Electric Field Navigated 1Hz rTMS for Post-stroke Motor Recovery Trial) included 5 of 12 NICHE trial outpatient US rehabilitation centers. The stimulation protocol remained identical (1 Hz repetitive transcranial magnetic stimulation, M1_CL, preceding 60-minute therapy, 18 sessions/6 wks; parallel arm randomized clinical …

Feasibility Of Supervised Telehealth Exercise For Patients With Advanced Melanoma Receiving Checkpoint Inhibitor Therapy, Brendan J. Crosby, Robert U. Newton, Daniel A. Galvão, Dennis R. Taaffe, Pedro Lopez Da Cruz, Tarek M. Meniawy, Muhammad A. Khattak, Wei-Sen Lam, Elin S. Gray, Favil Singh

Research outputs 2022 to 2026

Purpose: To determine the feasibility, safety and preliminary efficacy of a telehealth supervised exercise programme in patients with advanced melanoma receiving checkpoint inhibitor therapy. Methods: A 8-week non-randomised feasibility pilot trial utilising a telehealth delivered multimodal exercise programme undertaken thrice weekly with assessments at baseline and post-intervention. The study was considered feasible if there were no severe or life-threatening adverse events as a result of exercise, and three or more of the following criteria were met: the recruitment rate was > 50%, completion rate was > 80%, median programme attendance was > 75%, median exercise compliance > 75%, and average tolerance was > 70%. Preliminary …

A Mixed-Methods Exploration Of Quality Of Life In Forensic Inpatients With Schizophrenia Spectrum Disorders On The Social Learning Program, Alexa Hutzenbiler

Antioch University Dissertations & Theses

This mixed-methods study explored the quality of life and lived experiences of adult individuals with diagnoses of schizophrenia spectrum disorders residing and receiving treatment on the Social Learning Program (SLP) at Fulton State Hospital, a high-security state forensic facility. Eleven participants completed the WHOQOL-BREF quantitative quality-of-life measure. Ten participants completed in-depth, semi-structured, qualitative interviews. Interviews were transcribed then analysed using Interpretive Phenomenological Analysis. The major themes that emerged included “Working the Program,” “Relationship Dynamics with Self and Others,” “Meaning,” “I’ve Been Having Breakthroughs,” and “Areas for Improvement in the Program.” Combined, the findings of the present investigation demonstrate the utility …

Acute Kidney Injury Contributes To Worse Physical And Quality Of Life Outcomes In Survivors Of Critical Illness, Kirby P. Mayer, Victor M. Ortiz-Soriano, Alborz Kalantar, Joshua Lambert, Peter E. Morris, Javier A. Neyra

Physical Therapy Faculty Publications

Objectives: Survivors of critical illness and acute kidney injury (AKI) are at risk of increased morbidity. The purpose of this study was to compare physical, emotional, and cognitive health in survivors of critical illness with and without AKI.

Methods: Retrospective cohort study of adult (≥ 18 years old) survivors of critical illness due to sepsis and/or acute respiratory failure who attended follow-up in a specialized ICU Recovery Clinic. Outcomes were evaluated during 3-month visit and comprised validated tests for evaluation of physical function, muscle strength, cognitive and emotional health, and self-reported health-related quality of life (HRQOL). Descriptive statistics …

The Effects Of Home-Based Exercise Therapy For Breast Cancer-Related Fatigue Induced By Radical Radiotherapy, Georgios Mavropalias, Prue Cormie, Carolyn J. Peddle-Mcintyre, Daniel A. Galvão, Dennis R. Taaffe, Christelle Schofield, Sharon Ray, Yvonne Zissiadis, Robert U. Newton

Research outputs 2022 to 2026

Background: Radiotherapy (RT) can lead to cancer-related fatigue (CRF) and decreased health-related quality of life (HRQoL) in breast cancer patients. The purpose of this trial was to examine the feasibility and efficacy of a home-based resistance and aerobic exercise intervention for reducing CRF and improving HRQoL in breast cancer patients during RT. Methods: Women with breast cancer (N = 106) commencing RT were randomized to 12 weeks of home-based resistance and aerobic exercise (EX) or usual care/control (CON). The primary endpoint was CRF, with secondary endpoints of HRQoL, sleep duration and quality, and physical activity. Measurements were undertaken prior to …

The Joy Of Cooking With Ots: A Visual Guide, Sarah Baker

WWU Honors College Senior Projects

Access to the full guide found here: https://mixam.com/share/60bf9e1ed250502f2e67534e

Occupational therapy (OT) is an allied healthcare profession that is uniquely situated at the intersection of art and science. OT seeks to improve quality of life by addressing occupations, or daily activities that are meaningful and purposeful (Nelson, 2014). In order to accomplish these goals, occupational therapists (OTs) must use design thinking through the lens of evidence-based practice. This artistic creativity paired with well-researched scientific findings mimics the visual nature of this guide, which prioritizes this need for alternative representation of the sciences.

This visual guide focuses on the interconnectivity of culture, …

Healing Right Way: Study Protocol For A Stepped Wedge Cluster Randomised Controlled Trial To Enhance Rehabilitation Services And Improve Quality Of Life In Aboriginal Australians After Brain Injury, Elizabeth Armstrong, Juli Coffin, Deborah J. Hersh, Judith M. Katzenellenbogen, Sandra Thompson, Leon Flicker, Meaghan Mcallister, Dominique A. Cadilhac, Tapan Rai, Erin Godecke, Colleen Hayward, Graeme J. Hankey, Neil M. Drew, Ivan Lin, Deborah Woods, Natalie Ciccone

Research outputs 2014 to 2021

Introduction: Despite higher incidence of brain injury among Aboriginal compared with non-Aboriginal Australians, suboptimal engagement exists between rehabilitation services and Aboriginal brain injury survivors. Aboriginal patients often feel culturally insecure in hospital and navigation of services post discharge is complex. Health professionals report feeling ill-equipped working with Aboriginal patients. This study will test the impact of a research-informed culturally secure intervention model for Aboriginal people with brain injury.

Methods and Analysis: Design: Stepped wedge cluster randomised control trial design; intervention sequentially introduced at four pairs of healthcare sites across Western Australia at 26-week intervals.

Recruitment: Aboriginal participants aged ≥18 years …

The Efficacy Of Resistance Training In Addition To Usual Care For Adults With Acute Burn Injury: A Randomised Controlled Trial, Paul M. Gittings, Benedict M. Wand, Dana A. Hince, Tiffany L. Grisbrook, Fiona M. Wood, Dale W. Edgar

Physiotherapy Papers and Journal Articles

Resistance training immediately after a burn injury has not been investigated previously. This randomised, controlled trial assessed the impact of resistance training on quality of life plus a number of physical, functional and safety outcomes in adults with a burn injury. Patients were randomly assigned to receive, in addition to standard physiotherapy, four weeks of high intensity resistance training (RTG) or sham resistance training (CG) three days per week, commenced within 72h of the burn injury. Outcome data was collected at six weeks, three and six months after burn injury. Quality of life at 6 months was the primary endpoint. …

A Systematic Review Of The Efficacy Of Cognitive Stimulation Therapy (Cst) On Quality Of Life In Persons With Dementia, R. Babiarz, B. Haden, S. Karlin, J. Mark, A. Williams, M. Ferraro, M. C. Potvin

Student Papers, Posters & Projects

Quality of life (QoL) is an established outcome measure of patients with dementia and is strongly influenced by an individual's environment and mood. While there are many outcomes that can be examined with Cognitive stimulation therapy (CST) interventions, this systematic review focused on quality of life.

A Quantitative Comparison Of Arm Activity Between Survivors Of Breast Cancer And Healthy Controls: Use Of Accelerometry, Mary Insana Fisher, Claire C. Davies, Timothy L. Uhl

Physical Therapy Faculty Publications

Purpose

Survivors of breast cancer (BC) on the non-dominant side have more persistent deficits than those with cancer on the dominant limb. What is not known is whether those with BC use their involved upper limbs more, less, or at the same level as women without BC. Accelerometer use offers a quantifiable method to measure activity levels of upper limbs. The purpose of this study was to quantify the activity levels of the non-dominant involved limb among survivors of BC and compare these values to their dominant limb, as well as the non-dominant limb of a control group.

Methods

Participants …

Yoga-Specific Enhancement Of Quality Of Life Among Women With Breast Cancer: Systematic Review And Exploratory Meta-Analysis Of Randomized Controlled Trials, Daline El-Hashimi, Kevin M. Gorey

Social Work Publications

Physical activities during and after cancer treatment have favorable psychosocial effects. Increasingly, yoga has become a popular approach to improving the quality of life (QoL) of women with breast cancer. However, the extant synthetic evidence on yoga has not used other exercise comparison conditions. This meta-analysis aimed to systematically assess yoga-specific effects relative to any other physical exercise intervention (eg, aerobics) for women with breast cancer. QoL was the primary outcome of interest. Eight randomized controlled trials with 545 participants were included. The sample-weighted synthesis at immediate postintervention revealed marginally statistically and modest practically significant differences suggesting yoga’s potentially greater …

Response Shift After A 4-Week Multimodal Intervention For Chronic Ankle Instability, Cameron J. Powden, Matthew C. Hoch, Beth E. Jamali, Johanna M. Hoch

Rehabilitation Sciences Faculty Publications

Context The accurate evaluation of self-reported changes in function throughout the rehabilitation process is important for determining patient progression. Currently, how a response shift (RS) may affect the accuracy of self-reported functional assessment in a population with chronic ankle instability (CAI) is unknown.

Objective To examine the RS in individuals with CAI after a 4-week multimodal rehabilitation program.

Design Controlled laboratory study.

Setting Laboratory.

Patients or Other Participants Twenty adults (5 men, 15 women; age = 24.35 ± 6.95 years, height = 169.29 ± 10.10 cm, mass = 70.58 ± 12.90 kg) with self-reported CAI participated. Inclusion criteria were at …

Patients' Perceptions And Patient-Reported Outcomes In Progressive-Fibrosing Interstitial Lung Diseases, Jeffrey J. Swigris, Kevin K. Brown, Rayid Abdulqawi, Ketan Buch, Daniel F. Dilling, Dirk Koschel, Krishna Thavarajah, Rade Tomic, Yoshikazu Inoue

Internal Medicine Faculty Publications

The effects of interstitial lung disease (ILD) create a significant burden on patients, unsettling almost every domain of their lives, disrupting their physical and emotional well-being and impairing their quality of life (QoL). Because many ILDs are incurable, and there are limited reliably-effective, life-prolonging treatment options available, the focus of many therapeutic interventions has been on improving or maintaining how patients with ILD feel and function, and by extension, their QoL. Such patient-centred outcomes are best assessed by patients themselves through tools that capture their perceptions, which inherently incorporate their values and judgements. These patient-reported outcome measures (PROs) can be …

Patients' Perceptions And Patient-Reported Outcomes In Progressive-Fibrosing Interstitial Lung Diseases, Jeffrey J. Swigris, Kevin K. Brown, Rayid Abdulqawi, Ketan Buch, Daniel F. Dilling, Dirk Koschel, Krishna Thavarajah, Rade Tomic, Yoshikazu Inoue

Internal Medicine Faculty Publications

The effects of interstitial lung disease (ILD) create a significant burden on patients, unsettling almost every domain of their lives, disrupting their physical and emotional well-being and impairing their quality of life (QoL). Because many ILDs are incurable, and there are limited reliably-effective, life-prolonging treatment options available, the focus of many therapeutic interventions has been on improving or maintaining how patients with ILD feel and function, and by extension, their QoL. Such patient-centred outcomes are best assessed by patients themselves through tools that capture their perceptions, which inherently incorporate their values and judgements. These patient-reported outcome measures (PROs) can be …

Immersive Virtual Reality For The Management Of Pain In Community-Dwelling Older Adults., Sara Benham, Minhee Kang, Namrata Grampurohit

Department of Occupational Therapy Faculty Papers

Immersive virtual reality (VR) can provide a high level of engagement and distraction analgesia to address pain. However, community-based applications of this technology for older adults have not been studied. The objective of this study was to examine the applicability and effectiveness of an immersive VR intervention for pain, depression, and quality of life (QOL) in older adults. This pretest–posttest, mixed-methods design included senior center members (n = 12) with pain that interfered with daily functioning. The outcomes included the Numeric Pain Rating Scale, Patient-Reported Outcomes Measurement Information System (PROMIS^®) depression scale, World Health Organization Quality of Life …

Hand Issues On Scleroderma Patients, Ana Font Hernandez

Publications and Research

Based on the design of a 3D-printed spoon prototype, we surveyed scleroderma patients about the device's value. 75% of patients mentioned having problems on their hands due to scleroderma. 85% of patients said their hand form changed because of the disease. Answers to the frequency or speed of the changes provide inconclusive results. The 3D printing technology has the potential to solve specific issues scleroderma patients face in their daily lives. Nevertheless, further research is needed to fully understand how hands shape change over time.

Emerging Opportunities: Lymphedema Management And The Potential For Surveillance Methods In A Primary Care Model, Claire Brummet, Nicole Chang, Kayleigh Odgear

School of Occupational Therapy Master's Capstone Projects (2016-2021)

Heidi Shaffer, OTR/L, MSM, CLT-LANA at MultiCare-Gig Harbor was interested in how early intervention, namely intervening at Stage 0, related to better outcomes for oncology patients at risk of lymphedema. This question was developed from a desire to follow-up prior student research relating to the usefulness of the LDEX in lymphedema management, however current literature did not indicate the LDEX as an early intervention method. Although the authors did not exclude other types of cancer, the research only reflected breast cancer outcomes. Overall, strong evidence was found that exercise is not contraindicated for clients at risk of breast cancer related …

Quality Of Life During Treatment With Chemohormonal Therapy: Analysis Of E3805 Chemohormonal Androgen Ablation Randomized Trial In Prostate Cancer, Alicia K. Morgans, Yu-Hui Chen, Christopher J. Sweeney, David F. Jarrard, Elizabeth R. Plimack, Benjamin A. Gartrell, Michael A. Carducci, Maha Hussain, Jorge A. Garcia, David Cella, Robert S. Dipaola, Linda J. Patrick-Miller

Internal Medicine Faculty Publications

Purpose

Chemohormonal therapy with docetaxel and androgen deprivation therapy (ADT+D) for metastatic hormone-sensitive prostate cancer improves overall survival as compared with androgen deprivation therapy (ADT) alone. We compared the quality of life (QOL) between patients with metastatic hormone-sensitive prostate cancer who were treated with ADT+D and those who were treated with ADT alone.

Methods

Men were randomly assigned to ADT+ D (six cycles) or to ADT alone. QOL was assessed by Functional Assessment of Cancer Therapy-Prostate (FACT-P), FACT-Taxane, Functional Assessment of Chronic Illness Therapy-Fatigue, and the Brief Pain Inventory at baseline and at 3, 6, 9, and 12 months. The …

Overwhelming Research And Clinical Evidence Of Exercise Medicine Efficacy In Cancer Management—Translation Into Practice Is The Challenge Before Us, Robert Newton

Research outputs 2014 to 2021

The paper “Connecting people with cancer to physical activity and exercise programs: a pathway to create accessibility and engagement”1 is very timely. As the authors have convincingly demonstrated, rigorous clinical and research evidence support something of which most medical and allied health professionals are cognizant: the benefit of physical activity and exercise for people with cancer.

Timing And Amount Of Physical Therapy Treatment Are Associated With Length Of Stay In The Cardiothoracic Icu, Audrey M. Johnson, Angela N. Henning, Peter E. Morris, Alejandro G. Villasante Tezanos, Esther E. Dupont-Versteegden

Physical Therapy Faculty Publications

Significant variability exists in physical therapy early mobilization practice. The frequency of physical therapy or early mobilization of patients in the cardiothoracic intensive care unit and its effect on length of stay has not been investigated. The goal of our research was to examine variables that influence physical therapy evaluation and treatment in the intensive care unit using a retrospective chart review. Patients (n = 2568) were categorized and compared based on the most common diagnoses or surgical procedures. Multivariate semi-logarithmic regression analyses were used to determine correlations. Differences among patient subgroups for all independent variables other than age and …

Effect Of Life Review On Quality Of Life For Older Adults Living In Nursing Homes, Rene' Wren

Occupational Therapy Collection

Aim: To examine the effects of life review on daily activities, social participation, outlook on life, and perceptions of living in a nursing home measured by life satisfaction and quality of life in older adults.

Method: The study design was a two-phase quasi-experimental pre-post-tests including development and testing of a life review protocol. Nine residents, age ≥65, participated in a life review group once weekly for 6 weeks. Outcomes were analyzed using the Life Satisfaction Index-Z (LSI-Z) and pre-post surveys.

Results: LSI-Z scores improved post-intervention and survey outcomes indicated participation in activities of daily living (ADLs), socialization, …

Three-Year Trajectories Of Global Perceived Quality Of Life For Youth With Chronic Health Conditions, Janette Mcdougall, David J. Dewit, Megan Nichols, Linda Miller, F. Virginia Wright

Occupational Therapy Publications

Purpose Objectives of this longitudinal study were to examine 3-year trajectories of global perceived quality of life (QOL) for youth with chronic health conditions, as obtained from youth and parent reports, and to identify personal and environmental factors associated with the trajectory groups for each perspective.

Methods Youth with various chronic conditions aged 11–17 years and one of their parents were recruited from eight children’s treatment centers. Latent class growth analysis was used to investigate perceived QOL trajectories (separately for youth and parent perspectives) over a 3-year period (four data collection time points spaced 12 months apart). Multinomial logistic regression …

Clinical Pain Scale Compendium, Tiffany M. Crow, Nicholas J. Pilch, James P. Aiken

Physical Therapy Research Symposium

Title: Clinical Pain Scale Compendium

Authors: James Aiken, SPT1, Tiffany Crow, SPT1, Nicholas Pilch, SPT1

Affiliation(s): 1. Physical Therapy Program, University of Puget Sound

Theory:

Pain is one of the pivotal aspects of a healthcare examination. Clinicians cannot measure pain objectively, and thus, we can only obtain a subjective report of the patient’s experience. However, the human experience of pain can be measured beyond merely its intensity. The purpose of this compendium is to present a range of pain aspects; the who, what, where, when, and how much of pain measurement. This is accomplished with the following domains: affective, beliefs, …

Quality Of Life And Self-Determination: Youth With Chronic Health Conditions Make The Connection, Janette Mcdougall, Patricia Baldwin, Jan Evans, Megan Nichols, Nicole Ehterington, Virginia Wright

Occupational Therapy Publications

While optimizing quality of life(QOL) is a key goal of rehabilitation care,no previous study has reported on what ‘QOL’ means to youth with chronic health conditions. In addition, no qualitative studies have explored the relationship between QOL and self-determination(SD). Objectives of this qualitative study were to examine: what the terms ‘quality of life’ and ‘self-determination’ mean to youth with chronic conditions; the factors these youth think are linked with these concepts; the relationship they see between concepts, the types of future goals youth have and how they view the connection between their SD and these goals. A descriptive methodology was …

Wordless Intervention For Epilepsy In Learning Disabilities (Wield): Study Protocol For A Randomized Controlled Feasibility Trial, Marie-Anne Durand, Bob Gates, Georgina Parkes, Asif Zia

Dartmouth Scholarship

Epilepsy is the most common neurological problem that affects people with learning disabilities. The high seizure frequency, resistance to treatments, associated skills deficit and co-morbidities make the management of epilepsy particularly challenging for people with learning disabilities. The Books Beyond Words booklet for epilepsy uses images to help people with learning disabilities manage their condition and improve quality of life. Our aim is to conduct a randomized controlled feasibility trial exploring key methodological, design and acceptability issues, in order to subsequently undertake a large-scale randomized controlled trial of the Books Beyond Words booklet for epilepsy.

A Rehabilitation Program For Lung Cancer Patients During Postthoracotomy Chemotherapy, Amy J. Hoffman, Ruth Ann Britnall, Alexander Von Eye, Lee W. Jones, Gordon Alderink, Lawrence H. Patzelt, Jean K. Brown

Peer Reviewed Articles

Objective: The objective of this pilot study was to describe the effects of a 16-week home-based rehabilitative exercise program on cancer-related fatigue (CRF), other symptoms, functional status, and quality of life (QOL) for patients with non-small cell lung cancer (NSCLC) after thoracotomy starting within days after hospital discharge and continuing through the initiation and completion of chemotherapy.

Materials and methods: Five patients with NSCLC completed the Brief Fatigue Inventory (measuring CRF severity) and the MD Anderson Symptom Inventory (measuring symptom severity) before and after thoractomy, and at the end of each week of the 16-week exercise program. Additionally, the Medical …

Icf-Based Functional Components And Contextual Factors As Correlates Of Perceived Quality Of Life For Youth With Chronic Conditions, Janette Mcdougall, Virginia Wright, David Dewit, Linda Miller

Occupational Therapy Publications

Purpose: To explore International Classification of Functioning, Disability and Health (ICF)-based functional components and contextual factors associated with perceived quality of life (QOL) for youth with chronic conditions from the perspective of youth and parents.

Method: Baseline data were obtained from a longitudinal study examining predictors of changes in perceived QOL for youth with chronic conditions. 439 youth aged 11–17 (and one of their parents) completed a questionnaire. Standardized tools were used to measure youth functioning, contextual factors and perceived QOL. Multivariate linear regression analyses, controlling for socio-demographic and health information, were conducted to explore correlations among youth functioning/contextual factors …